P1

Prevalence of Sarcopenia Among Prostate Cancer Patients in Korea

Byung Joo Lee1*, So Youn Chang1, Min Suk Kang1, Jong In Lee1†

College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Department of Rehabilitation Medicine1

Objective Sarcopenia refers to a decrease in skeletal muscle or lean body mass (LBM). Prostate cancer is second most commonly diagnosed cancer in male. The pharmacological suppression of testosterone by androgen deprivation therapies (ADT) has become a mainstay of treatment in prostate cancer patients with or without surgery. Although applying of ADT improves cancer-specific mortality, decline in testosterone leads to a number of side effects, including loss of LBM and increase in fat mass. The aim of this study is to examine the prevalence of sarcopenia and the effect of ADT on development of sarcopenia in prostate cancer patients. Methods Patients with prostate cancer who had undergone a surgery or ADT had been recruited. Inclusion criteria were 1) Korean male 60-year-old or above, 2) diagnosed with prostate cancer stage I or II (histologically confirmed after undergone radical prostatectomy or had radical radiotherapy) or on current ADT (due to advanced stage of prostate cancer or recurrence of cancer after radical therapy), 3) written informed consent. Exclusion criteria were 1) having treatment within a recent month due to active malignant disease, 2) having bone pain due to bone metastasis or having risk of pathologic fracture, 3) inability to perform 2-minute-walk test, 4) received total knee replacement arthroplasty or total hip replacement arthroplasty, 5) inappropriateness to participate in exercise due to other reasons based on physician’s judgement. The sarcopenia was evaluated by using the Asian Working Group for Sarcopenia criteria. Results A total of 86 patients were evaluated. The prevalence of sarcopenia was 12.8% in prostate cancer patients. In subgroup analysis, 6 out of 29 patients (20.7%) in ADT group and 5 out of 57 patients (8.8%) in non ADT group had sarcopenia. The non ADT group showed higher grip strength (p=0.009), skeletal muscle mass index (p=0.019), 2-minute walking distance (p=0.019), and 1 repetition maximum in lower extremity (p=0.016). Conclusion The results suggest that sarcopenia is more prevalent in prostate cancer patients than in general population. ADT has tendency to have an provocative effect on development of sarcopenia. However further study is needed to confirmed the relationshi

Application of the Asian Working Group for Sarcopenia algorithm for the study participants

P2

Analysis of Conversion Factors from Three Type of MCI to Dementia Using Long-term Care Service Data

Han Eol Cho1*, Hyoung Seop Kim2†, Jong Hun Kim3, Hyunsun Lim4

Yonsei University College of Medicine, Department of Rehabilitation medicine1, National Health Insurance Service Ilsan Hospital, Department of Rehabilitation Medicine2, National Health Insurance Service Ilsan Hospital, Department of Neurology3, National Health Insurance Service Ilsan Hospital, Research and analysis team4

Introduction By using the grade of long term care service, we can indirectly see the transition from amnestic mild cognitive impairment (aMCI) to dementia. The purpose of the study was to investigate the factors affecting the conversion of aMCI to dementia using data of long term care services and to identify deterioration factors of cognition. Methods Based on the Clinical Research Center for Dementia (CRCD) cohort registry from 2005 to 2013, we made a new cohort by merging it with the data from long term care service of National Health Insurance Service(NHIS). We enrolled 3569 patients with aMCI who satisfied the criteria : 1) presence of memory complaints 2) intact function in activities of daily living (ADL); (3) objective cognitive impairment (at least 1.0 standard deviation [SD] below age- and education-adjusted norms) in more than one cognitive domain on standardized neuropsychological testing. All participants completed a complete medical interview, clinical dementia rating (CDR), and brain MRI scan. We obtained information about the age, sex, education, income level, and accompanying diseases (hypertension, diabetes, hyperlipidemia) of the participants. Also, we figured out whether or not patients get were receiving the long-term care service. Transaxial T2 and FLAIRS images of brain were obtained using a 1.5T MRI scanner. We classified the severity of white matter hyperintensity(WMH) change on MRI according to the criteria of Table 1. The patients were classified according to the severity of white matter hyperintensty(WHM) change: aMCI, aMCI with moderate WMH change(aMCI with), aMCI with sever WMH change(svMCI). Results Baseline characteristics of the participants are summarized in Table 2. The number of women was about two times higher than that of men, and statistically significant. (p = 0.016). Education period tended to be shorter in the group of severe ischemic change. When comparing the time period of receiving long term care service, hazard ratio of aMCI with was 1.27 based on aMCI, but it was not statistically significant. In the case of svMCI, the time period of receiving long term care service was 1.29 and statistically significant compared with aMCI. (Table 3, Figure1). We sought to determine what factors predicted incident dementia. Severe baseline WMH change, advanced age, female, long educational period, higher CDR scores at baseline significantly predicted dementia in univariate analysis. In multivariate analysis, severe WMH change, advanced age, female

and higher CDR scores at baseline significantly predicted progression to dementia Conclusions Our findings suggest that severe WMH change, advanced age, female and higher CDR scores at baseline were significant factors that predict progression from MCI to dementia.

Fig 1. Kaplan-Meier Graph from the first day of diagnosis as aMCI patient due to WMH change to the first

day of receiving long term care service

P3

Comparison of videofluoroscopy and fiberoptic endoscopic evaluation of swallowing in dysphagia

Da Hwi Jung1, Sang Hun Kim1, Myung Hun Jang1, Yong Beom Shin1, Jin A Yoon1*†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Objective Videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) has their strengths and combining these two improved sensitivity of detecting aspiration and residue compared to single study. The aim of the study was to compare the findings of VFSS and FEES. Method The 3.0mm flexible fiberoptic endoscope Pentax CP-1000, VNL9-CP (Pentax Japan Inc., Tokyo, Japan) were applied. VFSS was performed using Toshiba Ultimax-I DREX-UI80 (Toshiba America Medical System, Inc., Tustin, USA). We used barium impregnated during 1, 5, 10, 20ml of thin liquid, 2 spoonfuls (3ml) of puree (yogurt). 3 raters judged the severity of residue and laryngeal penetration or tracheal aspiration with blinded to the participant details. The raters scored Penetration-Aspiration Scale (PAS) (Figure 1A). Post-swallow residue during VFSS was measured by Normalized Residue Ratio Scale (NRRS), ratio of residue relative to available valleculae, pyriform sinus space (Figure 2). Residue severity of FEES was scored by Yale Pharyngeal Residue Severity (Table 1) (Figure 1B). Result A total of 178 participants (55 females and 123 males; mean age 62.8 yrs ± 14.1 SD) were enrolled. The reasons of dysphagia were stroke in 53 (29.7%), traumatic brain injury in 27 (15.1%) cervical spinal cord injury in 36 (20.2%), head-neck cancer in 5 (2.8%), Parkinson disease in 6 (3.3%), others in 43 (24.1%). Intra-rater agreement between VFSS and FEES was substantial (κ = 0.655, p = 0.000) for PAS, valleculae retention (κ = 0.638, p = 0.000) and pyriform sinus retention (κ = 0.687, p = 0.000). The mean PAS score on FEES was 0.30 point, valleculae retention score was 0.18 point higher on VFSS, pyriform sinus retention was 0.15 point higher on FEES but all were not statistically significant (Table 2). 16 patients with food coating at true vocal cord during FEES showed tracheal aspiration on VFSS (Table 3). Vocal cord palsy and incomplete contact were significantly associated with tracheal aspiration in FFES findings (Table 4). Discussion Recent studies comparing the result of two exams found FEES consistently showed a worse scoring in PAS and residue scale compared to VFSS. However, the standard to define the presence of aspiration and residue severity were ambiguous and not generally quantitative. Our aspiration and retention scaling with recently proved reliable scaling system showed no statistical significant difference between two groups which could be useful to combine interpret the result of both studies and determine most appropriate

diet recommendation. Otherwise, food spillage into posterior larynx and invisible residue on the subglottic shelf could not exclude tracheal aspiration. Conclusion PAS, post swallow retention severity scores showed substantial agreement and no significant difference between VFSS and FEES. Combining VFSS and FEES considering different advantage of each exam would be desirable for dysphagia evaluation.

Fig 1. Residue on the subglottic shelf after liquid diet, Figure 1B: Severe valleculae, Moderate pyriform sinus

retention according to Yale Pharyngeal Residue severity rating scale

Fig 2. Post-swallow residue measured by Normalized Residue Ratio Scale (NRRS)

P4

Structural brain changes of mild traumatic brain injury patients: a tensor-based morphometry study

Eunkyung Kim1*, Han Gil Seo1, Hyun Haeng Lee2, Seung Hak Lee1, Seung Hong Choi3, Roh-Eul Yoo3, Won-Sang Cho4, Seo Jung Yun1, Min-Gu Kang1, Byung-Mo Oh1†

Seoul National University Hospital, Department of Rehabilitation Medicine1, Konkuk University Hospital, Department of Rehabilitation Medicine2, Seoul National University Hospital, Department of Radiology3, Seoul National University Hospital, Department of Neurosurgery4

Introduction Despite the negative findings of structural MR images in mild traumatic brain injury patients (mTBI) in clinics, there was clear evidence showing structural brain alterations in mTBI [1,2]. The aim of this study was to examine structural brain changes of mTBI compared to controls using a tensor-based morphometry (TBM) [3], capturing regional volume expansion and contraction. Since time post injury influence on brain changes significantly [4], we also tried to examine the relationship between time post injury and structural brain changes of mTBI. Methods Twenty-two patients with mTBI were included in this study (5M/17F, mean age: 53±4.6 years). Time post injury was from 25 days to 46 months (177.1±321.7 days). As a control group, thirty subjects were included (9M/21F, mean age: 56.1±10.8 years). 3D T1 images were acquired through a 3T GE scanner. TBM was applied to the groups using following framework by SPM12. First, we manually aligned the anterior and posterior commissures and segmented the images. DARTEL template was created using the segmented gray matter, white matter, and cerebrospinal fluid tissue maps. In this stage, flow field maps were acquired containing deformation information between subject space and template. The template is the inter-subject coregistered image, so we should normalize it to the MNI space. Deformation and jacobian determinant maps were estimated representing local shape changes from the individual T1 images to the MNI template image. Jacobian determinant value above, and below 1 indicated volume expansion and contraction, respectively. For statistical analysis, log transformed jacobian determinant maps were compared between the groups by a two-sample t-test with age and total intracranial volume as nuisance variables. Relationship between the structural brain changes and time post injury was also examined using the correlation analysis with age and total intracranial volume as nuisance variables. Statistical significance was all set at uncorrected P<0.005, with number of voxels per cluster>50. Results Compared to the controls, significant volume expansion of the patients was observed in the cerebral cortices, and significant volume contraction was observed in the cerebellum, midbrain, and middle cerebellar peduncles (Table 1 and Figure 1A and B, respectively). More complex results were found in between the structural brain changes and time post

injury of the patients (Table 2 and Figure 2). Volume of the frontal areas including precentral, and extra-nuclear were expanded while the volume of the parietal areas including postcentral, and superior temporal regions were contracted when time post injury was increased. Conclusion Structural brain changes observed in the mTBI patients may indicate plastic changes and vulnerability of the brain due to traumatic injury. Time post injury may be associated with the changes significantly. Future study should be needed to understand the meaning of the results.

Table 1. Volume enlargement and contraction observed in the mTBI patients compared to the controls

(Uncorrected P < 0.005, cluster size > 50).

Table 2. Volume enlargement and contraction associated with time post injury of the patients (Uncorrected

P < 0.005, cluster size > 50).

Fig 1. (A) Volume expansion and (B) contraction observed in the patients compared to the controls.

Fig 2. (A) Volume expansion and (B) contraction correlated with time post injury of the patients.

P5

Correlation between gait analysis and subregional uptake of striatal dopamine transporter on 18F-CIT positron emission tomography in patients with idiopathic Parkinson disease

Hyun Min Jeon1*, Seong-Min Kim2, Dae Hyun Kim1†

Veterans Health Service Medical Center, Seoul, Department of physical medicine and rehabilitation1, Veterans Health Service Medical Center, Seoul, Department of neurology2

Objective To investigate subregional uptake of striatal dopamine transporter in patients with idiopathic Parkinson disease (IPD) in correlation with three-dimensional gait analysis (3DGA). Methods This retrospective study included 88 patients with IPD who underwent 18F-CIT Positron Emission Tomography(CIT-PET) and 3DGA between January 1, 2014 and December 31, 2016. The CIT-PET images were analyzed with 12 striatal subregional (bilateral, ventral striatum, anterior caudate, posterior caudate, anterior putamen, posterior putamen and ventral putamen) and 1 occipital volume of interest templates (Fig 1). Rt striatum of CIT-PET for all patients were set to more affected side according to clinical feature. The level of activity in each voxel of interest (VOI) was calculated. The specific to nonspecific binding ration (SNBR) was defined as follows: (mean standardized uptake value of the striatal subregional VOI – mean standardized uptake value of the occipital VOI)/mean standardized uptake value of the occipital VOI, considering occipital uptake to be nonspecific binding. The correlation between SNBR of 12 striatal subregional area and 3DGA was analyzed after controlling age effect using Pearson’s correlation coefficient. Results The mean SNBR of anterior putamen in all patients were positively correlated with contralateral maximal hip extension angle in stance phase and hip maximal flexion angle in swing phase. The mean SNBR of anterior caudate, ventral striatum, ventral putamen in the 46 patients with HY scale 1 were correlated with hypokinetic sign of contralateral limb such as decrease of hip/knee/ankle joint angle during gait cycle. The mean SNBR of posterior putamen and ventral putamen in the 23 patients with HY scale 2 were positively correlate with ilsilateral knee maximal extension moment. There is no correlation between the 19 patients with HY scale 3 and SNBR of entire striatum (Fig 2 & 3). Conclusion Hip control during gait cycle was mainly associated with the activity of anterior putamen which including in skeletomotor loop of basal ganglia. Hypokinetic sign was mainly associated with ventral striatum in mild IPD. Kinetics of knee was associated with ipsilateral ventral and posterior putamen in mild to moderate IPD.

Fig 1. 12 striatal subregional area of CIT-PET

Fig 2. The specific to nonspecific binding ration of 12 striatal subregional area according to HY scale

Fig 3. Correlation between SNBR and 3DGA

P6

Effects of RTMS on Cognition and Neuroplasticity in Subacute Stroke Patients

Sheng Lan Jin1*, Yeong Wook Kim1, Sung Ju Jee1, Min Kyun Sohn 1†

School of Medicine, Chungnam National University, Department of Rehabilitation Medicine1

Objective The purpose of this study is to determine the cognitive improvement and neurophysiological effects of repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex(L-DLPFC) in subacute stroke patients. Methods Twelve consecutive first-ever stroke patients with cognitive impairment were enrolled. All subjects were randomly assigned to real or sham stimulation group and completed 10 sessions of rTMS for 2 weeks (Figure 1). 10Hz of navigation rTMS were applied (5sec stimulation and 25sec resting, total 1500 pulses) on the L-DLPFC at 80% of resting motor threshold (rMT). At the time of baseline, 1 month and 3 months after stroke onset, all subjects received the cognitive, behavioral and depression assessments. In addition, the vascular cognitive impairment harmonization standards (VCIHS), motor evoked potentials (MEP), event-related potentials (ERPs) and resting state functional magnetic resonance imaging (RS fMRI) were completed for the neuroplasticity at baseline and 3 months after stroke onset. Results After the treatment period, the real stimulation group improved significantly in the Montreal Cognitive (MoCA), Fugl-Meyer Assessment (FMA), Modified Bathel Index (MBI) and Geriatric Depression Scale (GDS) compared with sham stimulation group. And these effects lasted after three months. Among the VCIHS parameters, Z- scores of executive and memory function showed higher delta value between baseline and 3months timepoints in rTMS group. The MEP showed higher TIME x GROUP interaction in the percentage of intracortical inhibition and facilitation amplitude ratio in right hand. It suggests that there is beneficial effect on premotor cortical excitability of rTMS. The change of P300 amplitude in ERPs was more increased in real stimulation group significantly. The RS fMRI analysis results showed more increased functional connectivity of left frontal pole, Middle frontal gyrus, posterior parietal cortex and Right posterior parietal cortex in real group after stimulation compare with the sham group. Conclusion These results suggest that high frequency rTMS on the L-DLPFC improves cognitive function and functional network activity in subacute stroke. The rTMS seems to be an recommendable treatment in stroke patients with cognitive impairment.

Fig1. Clinical Study Phase

P7

Anatomic localization of motor branch points of flexor digitorum superficialis

Dong Gyun Sohn1*, Jihye Park1, Young Jin Ko1†

The Catholic University of Korea Seoul St. Mary`s Hospital , Department of Rehabilitation Medicine1

Objective The aim of this study was to identify the location of the intramuscular nerve branchs of the flexor digitorum superficialis(FDS), and to provide accurate injection region of the botulinum toxin. Design In this study, 12 arms of fresh cadavers were anatomically dissected to find an intramuscular nerve endings to FDS. The entry site of the motor nerve into the muscle belly was recorded as the motor branch points(MBPs). The proximal limit points(PLPs) and the distal limit points(DLPs) of the terminal intramuscular nerve endings were recorded. The three parameters were expressed in longitudinal and transverse coordinates in relation to the reference line. The reference line was established between the most prominent point of the medial epicondyle and the center of line connecting radial and ulnar styloid process, considering the origin and the direction of FDS. The longitudinal coordinate was recorded as a percentage of the distance along the reference line, and the transverse coordinate was measured at right angles from the reference line. The longitudinal coordinates are shown as % ± SD, followed by the transverse coordinate in millimeter ± SD. Results The mean length of the reference line was 234.6 ± 11.2 mm. Two MBPs innervating the FDS were identified in all 12 arms. In the first main branch, the MBPs was located at 41.6 ± 2.6% in the longitudinal coordinate of the reference line, PLPs was located at 35.1 ± 4.1%, and DLPs was located at 53.4 ± 4.6%. And in the second main branch, corresponding values were 72.4 ± 4.5%, 67.5 ± 1.5% and 82.0 ± 5.7%, respectively. The transverse coordinate of each parameters is shown in Table 1. The mean values of the transverse coordinate was -0.2 ± 4.5 mm, indicating that each parameters did not deviate significantly from the reference line. Conclusions Previous studies used a reference line that did not take into account the direction of the FDS, so each parameters were deviated from the reference line in the transverse coordinate. In this study, we set the reference line considering the direction of FDS and confirmed the location of the second main branch as well as the first main branch. The MBP of the first main branch is about 40% of the reference line and the MBP of the second main branch s about 70%. This result will help to determine an optimal injection site for botulinum toxin to FDS.

Table 1. Location of the MBPs, the PLPs and DLPs of the flexor digitorum superficialis.

Fig 1. Photograph of an anatomic dissection showing the median nerve branch entering the flexor digitorum

superficialis.

P8

The Correlation Between Clinical Characteristics and Salivagram Findings in Patients With Stroke

Kwang Jae Yu1*, Jong Min Kim1, Zeeihn Lee1, Dae Hee Lee1, Ju Young Cho1, Hyunseok Moon1, Donghwi Park1†

Daegu Fatima Hospital, Department of Rehabilitation Medicine1

Objective We aimed to evaluate the correlation between radionuclide salivagram findings and clinical characteristics in stroke patients with dysphagia. By performing this study, we tried to identify high-risk factors of salivary aspiration in stroke patients with dysphagia. Methods The medical record of 101 stroke patients with dysphagia who underwent both videofluoroscopic swallowing study (VFSS) and radionuclide salivagram were analyzed retrospectively. The subjects were divided into two groups according to the presence of aspiration on a salivagram (group A; patients with aspiration on the salivagram, group B; patients with no aspiration on the salivagram). The differences between clinical characteristics and VFSS findings (penetration-aspiration scale [PAS]) between the two groups were analyzed. In addition, the same statistical analysis was performed according to the stroke lesion (hemispheric stroke vs. brainstem stroke). Results Sixteen out of 101 patients displayed salivary aspiration on the radionuclide salivagram. There were no significant differences in age, sex, and disease duration between the two groups. However, there were significant differences in PAS, mini-mental state examination (MMSE), global deterioration scale (GDS), total modified Bathel index (MBI) scores, and sub-scores of MBI (hygiene, bathing, food, voiding, dressing, bowel, transfer, gait) between two groups (p<0.05). For a more detailed analysis according to the stroke lesion, multivariate logistic regression analysis was performed separately in both patients with hemispheric and brain stem stroke. In a multivariate logistic regression analysis with forward stepwise method, the MMSE score was the only significant parameter for predicting positive findings in salivagram in patients with hemispheric stroke. In patients with brainstem stroke, however, transfer score (sub-score of MBI) was the only significant parameter for predicting positive findings in salivagram. The areas under the receiver operating characteristic curve (AUC) of the MMSE score in patients with hemispheric stroke for positive detection in salivagrams was 0.857 (95% CI, 0.758–0.926.;

p<0.0001). The optimal cut-off values was ８ or less for the MMSE score (sensitivity 90%, specificity 80.6%)(Figure 2-A). In patients with brain stem stroke, the AUC of the transfer MBI sub-score for positive detection in salivagrams was 0.839 (95% CI, 0.627–0.957.; p=0.0001). The optimal cut-off values 3 or less for the transfer MBI score (sensitivity 80%, specificity 77.78%)(Figure 2-B).

Conclusion In patients with stroke who complained of dysphagia, MMSE score and transfer MBI sub-score were correlated with salivary aspiration. Therefore, performing a radionuclide salivagram in hemispheric stroke patients with MMSE score of 8 or less or brainstem stroke patients with MBI score of 3 or less, performing radionuclide salivagram may help to detect salivary aspiration early.

Fig 1. Sequential images of radionuclide salivagram throughout 1 hour after oral administered of

technetium 99m sulfur colloid solution (A) The presence of radiotracer in trachea and bilateral bronchi

demonstrates positive for salivary aspiration (arrows). (B) Uptake of radiotracer noted only in oropharynx,

esophagus and stomach demonstrates negative for salivary aspiration.

Fig 2. ROC curve of MMSE and transfer MBI score for developing aspiration on radionuclide salivagram in

patients with stroke. The optimal cut-off value (dots on the curves), which was obtained from the maximal

Youden’s index, was score of 7 on MMSE for aspiration on radinuclide salivagram in patients with

hemispheric stroke (A) (AUC, 0.857; 95% confidential interval, 0.758–0.926; p<0.0001; sensitivity 90%,

specificity 80.6%) and transfer MBI sub-score for aspiration on radinuclide salivagram in patients with

brainstem stroke (B) (AUC, 0.839; 95% confidential interval, 0.627–0.957; p=0.0001; sensitivity 80%,

specificity 77.78%). ROC, receiver operating characteristic; AUC, area under the ROC curve.

P9

Diffusion tractography as a prognostic biomarker for motor recovery in patients with pontine infarct

Ja-ho Leigh1, Da Ye Kim1*, Hee Ju Yang1, Minuk Kim1†

The Catholic University of Korea Incheon St. Mary`s Hospital , Department of Rehabilitation Medicine1

PURPOSE To investigate the dynamic evolution of diffusion indexes in the corticospinal tract (CST) distal to a pontine infarct by using diffusion-tensor imaging, to determine the relationship of these indexes with clinical prognosis, and to explore the structural changes in the motor pathway during recovery. MATERIALS AND METHODS This study was approved by the institutional ethics committee, and written informed consent was obtained from each participant. Twenty-four patients (17 men; average age, 58.6 years; range, 42–83 years) were recruited for this study. All patients were diagnosed with pontine infarct and underwent diffusion-tensor imaging examinations after stroke (mean duration : 50±115 days). Reconstructions of the CST were performed. All Fiber numbers were measured in the medulla, cerebral peduncle, internal capsule, and centrum semiovale. Fiber numbers across the pons of the CST in the ipsilateral side of the infarct were calculated. Their relationships with clinical scores such as Fugl-Myer score, Berg balance test(BBS) and Modified Barthel index were analyzed by using Pearson correlation analysis. A P value of .05 (two tailed) was considered to indicate a significant difference for all statistical procedures. RESULTS All patients had some degree of motor deficit. The FM scale scores ranged from 0 to 66 at the first examination. The number of fiber across pons were correlated positively with BBS at discharge (r = 0.549, P = 0.005) and MBI at discharge(r=0.682, P=0.000). Fractional ratio of fiber across pons (The number of fiber across pons/total number of CST fiber) were correlated positively with BBS at discharge(r=0.423, P=0.039) and MBI at discharge (r=0.511, P=0.013). Difference between admission and discharge of MBI score was well correlated with the number of fiber across pons (r=0.436, P=0.038) diffusion-tensor tractographic images showed regeneration and reorganization of the motor pathways. CONCLUSION Secondary degeneration of the CST can be detected at diffusion-tensor imaging in the subacute stages after pontine infarction, which could help predict the motor outcomes. Diffusion-tensor tractography can allow detection of regeneration and reorganization of the motor pathways during recovery.

P10

The Effects of rTMS on long-term potentiation and gene expression in transgenic 5XFAD mice

Yuri Choe1*, Wang-in Kim2, Min-Keun Song2, Jihoon Jo3, Jae-Young Han2†

Gwangju Veterans Hospital, Department of Rehabilitation Medicine1, Chonnam National University Hospital, Department of Rehabilitation Medicine2, Chonnam National University medical school, Department of biomedical sciences3

Introduction Repetitive transcranial magnetic stimulation(rTMS) is a safe and painless noninvasive brain stimulation technique that has recently received increasing interest as a therapeutic neurorehabilitative tool. Transcranial magnetic stimulation(TMS) is fragmentarily reported to be beneficial to Alzheimer’s disease(AD). However little known about that high frequency rTMS is better than low frequency rTMS in AD. Objective The aim of this study was to investigate effect of rTMS on long-term potentiation(LTP) in Alzheimer’s dementia mice model(5X FAD) depends on frequency and to analyze the different biomechanical change in gene level using RNA sequencing technology. Method Fifteen Male transgenic mice (16-22 weeks old, 5X FAD) and fifteen age-matched Male C57BL/6J wild type model mice were used for experiments. Experimental mice were divided to 3 groups of five mice each according to the experimental schedule in order; control group (sham treatment), low frequency(LF) group (1Hz) and high frequency(HF) group (5Hz). The rTMS (intensity, 120% of RMT; duration, 10s; number of pulses, 50; wait time, 60s; number of trace, 10) was applied at 1 or 10Hz five days a week for 2 weeks to AD model mice (FAX5D), while the control group was treated with sham rTMS. All mice were sacrificed and brain tissues in hippocampus were taken and hippocampal LTP was tested within 2 days after the completion of rTMS schedule. We analyzed their gene expression by RNA sequencing technology. Results 1) LTP in the HF group (149.8±3%) was shown to be significantly enhanced than LTP in the LF group (116.7±3%) compared to control group. There was no significant difference in wild type group after the 1-Hz rTMS protocol and 5-Hz rTMS protocol. 2) Activation of p-GSKβ(s9) was significantly increased in AD model mice after 5-Hz rTMS. There were no significant differences in activation of Caspase-3 expression between HF group and LF group. 3) We found out the significant fold changes (p<0.05, fold change > 2 times, average of normalized read count (RC) > 4 times) in 4 genes (Grip1 ,Vwc2, Rom1 and Trp73) related to neurogenesis in LF group and 2 genes (Fmn1 and Naglu) in HF group. There was no overlapped up-regulated or down-regulated gene related to neurogenesis between LF group and HF group. 4) There was significant fold change in 2 genes related to aging in HF group compared with control group. Serping1 gene was up-regulated and

Serpine1 gene was down-regulated. 3) Serpine1 gene was significantly down-regulated in high-frequency group compared with control group. There was no significant fold change in any gene related to angiogenesis in low-frequency group compared with control group. Conclusion High-frequency rTMS significantly enhanced long-term potentiation in Alzheimer’s dementia mice model. Moreover, There is a possibility that the mechanism is high-frequency rTMS-induced down-regulation of SERPINE 1 gene.

Fig 1. Effects of repetitive transcranial magnetic stimulation depends on frequency

Fig 2. Activation of Cleaved C-3 and p- p-GSKβ(s9)

Fig 3. High frequency rTMS-induced Down-regulation of SERPINE1 gene Expression

P11

Objective Evaluation of Output Energy by Modulating the Intensity of the Infrared Diathermy

Kyu-Ho Lee1*, Min-Soo Jeon1, Il-Young Jung1, Kang Hee Cho 1,2†

Chungnam National University Hospital, Department of Rehabilitation Medicine, School of Medicine1, Chungnam National University, Department of Rehabilitation Medicine, Biomedical Engineering Center, School of Medicine2

Objective Infrared radiation is an invisible band of energy in the electromagnetic spectrums, which has been used to relief the pain. It transfers energy, in the form of heat that can be recognized by thermos receptors in the target tissue. Infrared is divided into near infrared, including infrared heaters and heat lamps (750–1400 nm) emitting temperatures of 1300 °C, medium infrared (1400–3000 nm) and emits temperatures of 500–800 °C and far infrared which, operates in the wave lengths above 3000 nm, and emits much lower temperatures and no visible light. This study aims to investigate whether the energy transfer amount increases with the intensity control of the infrared device. Methods We compared 14 infrared devices used in our hospital’s thermoelectric therapy sector. Infrared radiation output 20mW and peak wave length of 850 nm (IR-2009, Yeollin Sesang, Korea). The radiation output was measured using an laser power energy meter (NOVA II, OPHIR, Korea). An energy meter was placed at a distance of 30 cm from the IR light source, and the energy was measured while increasing the intensity from 1 to 10 after darkening the surrounding environment. Results The radiation energy of a total of 14 infrared devices were measured, and the output energy value was recorded according to the intensity change of 1 to 10. A linear increase in energy output was observed with increasing intensity in each infrared devices and statistical significance difference was observed. (P=0.001) The linear regression equation can be obtained by analyzing the data of the energy measurement data, and the energy transfer value according to the intensity change can be predicted. (Intensity = -0.486 + 0.324 X, r2=93.5) A statistical significantly difference between the two groups were also observed, as the energy output data can be grouped into two different groups of intensity variations. (P=0.001) Conclusions The results of this study can be used to predict the energy transfer value according to the intensity control of the infrared therapy device used in clinical practice. Energy output data analysis showed a linear increase in output energy transfer as the intensity of the devices was increased. Some device has a stronger energy transfer than the predicted value, standardization and quantification of infrared devices are required.

Fig 1. Characteristics of the infrared output energy value was recorded according to the intensity change of

1 to 10.

Fig 2. Comparison of the between the two groups as the increasing output energy variations. *, P=0.001 by

Mann-Whitney test.

P12

Relationship between Hand Bone Ages and Calcaneal Apophysis Ossification Staging

Seung-Wook No1*, Yong Min Choi1, Dong-KI Min2, Han Seong Choe3, Soyoung Lee1†

Keimyung University Dongsan Medical Center, Department of Rehabilitation Medicine1, Daegu Health College, Department of Physical Therapy2, Catholic University of Daegu, Department of Physical Therapy3

Introduction Although hand radiographs are used to assess pediatric growth, the measured bone age range is wide and may not accurate enough to predict when individuals development. In contrast, at the beginning of the ossification of the foot, the height growth tends to be very fast, and can be used to predict the individual’s growth spurt. The purpose of this study was to investigate relationship between hand bone ages and calcaneal apophysis ossification staging. Participants and Methods A retrospective review of medical records was performed on patients visited the department of developmental rehabilitation clinic from January 2013 to January 2018. A total of 207 patients (mean age: 7.7±3.0 years, Female:Male=106:101) who were taken hand and foot radiographs were engaged. Hand bone age was estimated by Tanner-Whitehous 2 (TW2) methods and foot ossification by calcaneal apophysis ossification staging system. Based on the hand bone age and chronological age, patients were grouped as ‘Delayed’, ‘Normal’, and ‘Advanced’. Pearson correlation coefficients were calculated in all groups to reveal the relationship between hand bone ages and calcaneal apophysis ossification staging. Result When comparing the value of hand bone age and calcaneal apophysis ossification staging, there is a moderate to strong correlation in all group. Statistical analysis of Pearson's correlation showed that strong relationship in ‘Advanced’ development group (r=0.783, p=0.000) and moderate relationship in ‘Normal’ and ‘Delayed’ development groups (r=0.541, p=0.000 and r=0.591, p= 0.001 respectively). In all group, boys and girls were classified, and calcaneal apophysis ossification staging according to their ages were graphically shown. (Fig. 1-3) Relationship between hand bone ages and calcaneal apophysis ossification staging was well correlated. Discussion There is a correlation between hand bone age and calcaneal apophysis ossification staging, and the strongest relationship in ‘Advanced’ development group, following ‘Delayed’ and ‘Normal’ group. Calcaneal apophysis ossification staging which is simply used in clinic, can also be used as an important evaluation tool of predicting growth and development.

Fig 1. Calcaneal apophysis ossification staging according to ages in ‘Delayed’ group.

Fig 2. Calcaneal apophysis ossification staging according to ages in ‘Normal’ group.

Fig 3. Calcaneal apophysis ossification staging according to ages in ‘Advanced’ group.

P13

Improved intraoperative motor evoked potentials and motor recovery after spinal cord tumor removal

Jinyoung Park1*, Soeun Pyo1, Yoon Ghil Park1†

Gangnam Severance Hospital, Department of Rehabilitation Medicine1

Objective Intraoperative neurophysiological monitoring (IONM) is commonly used technique for assessing nervous system during spinal or brain surgery. The consensus about the alarm criteria of motor evoked potentials (MEPs) and somatosensory evoked potentials (SEPs) have been evolving continuously to predict the poor functional prognosis after surgery. With no previous study, this study aims to find out whether the increase of the amplitude of MEPs can imply favorable prognosis in spinal cord tumor surgery Methods 1) Patients This is a retrospective cohort study between March 2016 and February 2018 in one institute. The IONM was performed in 115 patients with spinal cord tumor. With excluding 43 patients who were lost to follow up, medical data of 72 patients were analyzed. The strengths of bilateral 10 key muscles by manual muscle test documented a day before (Motorpre), 48 hours (Motor48hrs) and 4 weeks (Motor4wks) after the surgery were reviewed 2) IONM data The final peak-to-peak amplitudes changes of the N20 (deltoid or abductor polices brevis) or P37 (tibialis anterior or abductor halluces) of MEPs were reviewed. The amplitude changes at the end of monitoring compared to the baselines in each muscle were analyzed. Among the changes of MEPs in several muscles, the minimum and maximum changes were set to MEPmin (%) and MEPmax (%). 3) Statistical Analysis Pearson’s correlation analysis was used to find the correlation between Motorpre, Motor48hrs, Motor4wks, MEPmin, MEPmax, and bleeding amount Results The difference of Motor48hrs from Motorpre (Motor48hrs-pre) positively correlated with MEPmin (Pearson correlation coefficient 0.32 and P=0.01) (Fig. 1 & Table 1), suggesting that the smaller the difference of MEPs amplitude, the less recovery of muscle strength. Additionally, there was a negative correlation between the amount of bleeding and MEPmin (Pearson correlation coefficient -0.28 and P=0.02) (Fig 2 & Table 1), indicating that the greater the amount of bleeding, the smaller the MEPmin, implying that MEPs amplitude is less likely to improve when the amount of bleeding is large. Also, it showed no significant correlation between amount of bleeding and Motor48hrs-pre (P=0.19). There was no significant correlation between the difference of Motor4wks and Motorpre (Motor4wks –pre) and MEPmin (P=0.06) or MEPmax (P=0.40), respectively (Table 1) Conclusion This is the first study to investigate the correlation between amplitude increase in MEPs and the amount of motor recovery. This study showed that the recovery of muscle strength was less when the increase of MEPs amplitude was small, and that the

improvement of MEPs amplitude was less when the amount of bleeding was large. However, there was no direct correlation between the amount of bleeding and improvement in muscle strength maybe due to small sample size and small correlation coefficients. For delicate analysis, further studies including various parameters of IONM would be needed

Fig 1. Correlation between minimum change of amplitude of motor evoked potentials and improvement of

motor strength 48 hours after surgery

Fig 2. Correlation between amount of bleeding and minimum change of amplitude of motor evoked

potentials

Table 1. Pearson correlation coefficient and P-values between variables

P14

The effect of IT convergence gamification training in community-dwelling older people: Pilot study

Eun Gyeom Cha1*, Lee Eun Lee1, Yang Ja Gyeong2, Jung Gyu Jin3, Myoung-Hwan Ko4, Myung Jun Shin1,5†

Pusan National University Hospital, Department of Rehabilitation Medicine 1, Dongseo university , Department of exercise prescription2, Youngsan university , Marine leisure tourism3, Chonbuk National University Medical School, Department of Rehabilitation Medicine 4, Pusan National University School of Medicine, Department of Rehabilitation Medicine 5

Introduction/Background For the elderly, the reduction of motor function is natural phenomena, but requires a variety of concerns about how to slow down the rate of decline. Therefore, it is necessary to expand the exercise facilities or welfare facilities for the elderly, but the reality is suffering from space, cost problem and compliance. In the case of elderly people, the social exercise and the medical exercise therapy should be distinguished, but the boundary is usually ambiguous. Furthermore, exercise for the elderly, whether preventive or therapeutic, should be provided as a public service, but this is also difficult. Material and Method In this study, we tried to approach exercise therapy for improvement of elderly physical function such as walking, balance and flexibility etc. through gamification exercise equipment(Men&Tel, Korea, Balpro 110, Model No. SBT 110) (Figure 1). The elderly over 65 years of age were trained for 8 weeks(30 minutes/3 times/week) and the functional ability was evaluated after 4 weeks of rest. Both groups were randomized. Group 1 exercises were performed by conventional method, and Group 2 exercises were performed by IT convergence exercise equipment. Results There were both functional improvement in Group 1(10 patients) using conventional exercise and Group 2(10 patients) using Balpro 110 (Figure 2,3). In the first group, after 8 weeks of training, lower extremity muscle strength and balance ability, and body fat mass and skeletal muscle mass improved significantly. In the second group, leg strength, balance, mobility, walking abilities, flexibility, body fat and skeletal muscle mass were statistically significantly improved. Conclusion The results of this study suggest that the information technology convergence gamification device will be a supplementary tool for the exercise of the next generation elderly population and at the same time provide an opportunity to think about the future direction.

Fig 1. Men&Tel, Korea, Balpro 110, Model No. SBT 110

Fig 2. The effect of IT convergence gamification training in group1

Fig 3. The effect of IT convergence gamification training in group2

P15

Difference in the incidence of metabolic syndrome among the disabled and non-disabled people

Ha Ra Jeon1†, Sang Yoon Lee1*, Seong Woo Kim1, Jang Woo Lee1, Da Wa Jung1, Jun Min Cha1

National Health Insurance Service Ilsan Hospital, Departments of Physical Medicine and Rehabilitation1

Introduction The prevalence of metabolic syndrome is also increasing in Korea due to changes in diet and lifestyle. Metabolic syndrome is associated with cardiovascular disease, insulin resistance, and hypertension. Prevention and treatment of metabolic syndrome is considered to be important for lowering the social burden caused by metabolic syndrome. There are many studies to report the prevalence of metabolic syndrome and efforts to prevent and treat it in normal adult people. However, there are no studies about incidence of metabolic syndrome in disabled people. The aim of this study was to investigate the incidence of metabolic syndrome in the disabled people and to compare the incidence of the non - disabled people. Materials & Methods From 2002 to 2013, the data were analyzed based on the cohort data of the National Health Insurance Corporation. The metabolic syndrome was defined according to the ATP-III guideline. However, it was difficult to obtain data on waist circumference, TG, HDL-C, blood pressure, and fasting blood glucose. So metabolic syndrome was defined when people took medicines for hypertension, diabetic mellitus and dyslipidemia. Results The incidence of metabolic syndrome was 13.4% and 20.2% in the disabled and non - disabled, respectively. According to the age, the percentage of the under-40s was the lowest in the non-disabled group and the similar ratio was in the 50s, 60s, and 70s or older. However, all age groups showed similar rate in disabled group. When compared to the non - disabled group, the incidence rate of the metabolic syndrome was 1.43 times higher than the non - disabled group. According to gender, the incidence of metabolic syndrome in the disabled group was significantly higher in both men and women than in the non-disabled group. By age, the incidence of metabolic syndrome in disabled group was significantly higher in the under-40s and 60s than in non-disabled group. Conclusion There is a higher incidence of metabolic syndrome among people with disabilities than non-disabled people. Therefore, active health care is needed to prevent and manage the metabolic syndrome of the disabled.

P16

General Characteristics and Functional Outcomes in the Elderly Patients with Spinal Cord Injury

Na Ri Yun1*, Min Cheol Joo1†

Wonkwang University School of Medicine, Department of Rehabilitation Medicine1

Objectives To investigate the general characteristics and functional outcomes of the spinal cord injury (SCI) in elderly compared with younger patients. Methods We reviewed the medical records of the SCI patients who treated and discharged from inpatient rehabilitation clinic service of a tertiary medical institution, retrospectively. A total of 127 patients were enrolled, and divided into two groups according to age; 53 of elderly group (≥60 year) and 73 of younger group (<60 year). Demographics and clinical datas were collected such as age, gender, time since injury, length of hospital stay, cause of injury, severity and level of injury etc. The functional outcomes at admission and discharge were also analyzed; the Korean version of the modified Barthel Index (K-MBI), Spinal Cord Independence Measure II (SCIM II), Walking Index for Spinal Cord Injury (WISCI). Results The mean age of the elderly group was 68.3 ± 6.5 years, and younger group was 45.7 ± 11.6 years. In the elderly group, 30 males and 23 females were found, and 61 males and 12 females in the young group, there was a significant difference in the sex ratio. Marital and employment status, and discharge place were also significantly different between two groups. On the other hand, the hospital day was significantly shorter in the elderly group (25.4 ± 11.0) than in the younger group (31.4 ± 13.9) (Table 1). In the elderly group, with traumatic SCI 60.4% non-traumatic SCI 39.6%, the proportion of non-traumatic SCI was higher than the young group (Traumatic SCI: 76.3%, Non-traumatic SCI: 23.3%) (Table 1). Falls were the most frequent etiology (56.3%), general falls predominated (50.0%) in the elderly group. In contrast, transport accidents (44.6%) was the main cause in younger groups. In non-traumatic causes, spinal stenosis (23.8%) was most frequent in elderly group (Table 2). The functional outcomes at discharge were improved in both groups compared to admission. In elderly group, K-MBI (29.3 ± 22.0) and SCIM II (33.0 ± 23.1) at admission point were lower than younger group. After rehabilitation, the elderly group showed greater improvement in the K-MBI (elderly group: 14.9 ± 13.4, young group: 10.2 ± 9.9) than the younger group. In addition, the SCIM II was significantly more improved in the elderly group (elderly group: 13.0 ± 15.7, young group: 6.7 ± 11.1) (Table 3).

Conclusions The present findings showed that the elderly SCI patients differed from young SCI patients in the demographic characteristics, etiology and clinical features. Also, more intensive and adjusted rehabilitation therapy may be needed for the elderly SCI patients. Table 1.Demographic characteristics and baseline values of participants

Table 2. Etiology of traumatic and non-traumatic SCI

Table 3. Functional outcomes

P17

Distribution Patterns of Vulnerable Vessels Around Cervical Nerve Roots: A Ultrasound Imaging Study

Dae Hee Lee1*, Zeeihn Lee1, Jong-Min Kim1, Ju Young Cho1, Ju Seok Ryu2, Donghwi Park1†, Donghwi Park1

Daegu Fatima Hospital, Department of Rehabilitation Medicine1, Seoul National University Bundang Hospital, Department of Rehabilitation Medicine2

Backgrounds Despite these advantages of ultrasound, however, there has been no study of the vulnerable vessels in C3-7 during an ultrasound-guided cervical nerve root block (CNRB). Objectives To evaluate the prevalence of vulnerable vessels around the target of an ultrasound-guided cervical nerve root block (CNRB) at the cervical nerve root of C3-7 levels in a clinical setting. Design Restrospective, cross-sectional study Participants A total of 104 patients complaining of neck or arm pain with no prior surgical history and who had undergone an ultrasound-guided CNRB at an outpatient clinic from May 2015 to December 2017 were included. Results Out of 104 cases, the C3 level had seven blood vessels(8.33%), the C4 level had 14 blood vessels(13.86%), the C5 level had 17 blood vessels(16.35%), the C6 level had 27 blood vessels(25.96%), and the C7 level had 31 blood vessels(29.81%) either at the targeted cervical nerve root or at the site of the imaginary needle's projected pathway to the targeted cervical nerve root. Conclusion There was a non-neglectable prevalence of vulnerable vessels either at the targeted nerve root or at the site of the needle's projected pathway to the nerve root. Therefore, to prevent unexpected critical complications, it is recommended to routinely evaluate the vulnerable vessels around the cervical nerve root with color Doppler imaging in an ultrasound examination before CNRB.

Fig. 1 Flow chart of this study.

Fig. 2 (A)(B) Short axial ultrasound image showing the C3 transverse process. Note the nerve root (R), the

anterior tubercle (AT) and the posterior tubercle (PT) as the ‘2-humped camel’ sign. Solid arrows indicate

vulnerable vessel located in the posterior aspect of the intervertebral foramen. (C)(D) Short axial ultrasound

image showing the C4 transverse process. In contrast (C), solid arrows in (D) indicate vulnerable vessel

located in the posterior aspect of the intervertebral foramen. (E)(F) Short axial ultrasound image showing

the C7 transverse process. In contrast (E), solid arrows in (F) indicate vulnerable vessel located in posterior

aspect of intervertebral foramen.

Fig. 3 (A) Schematic illustration of the normal vascular anatomy around the cervical nerve root. (B)

Schematic illustration of the possible regional vascular anatomy around the cervical nerve root. There are

reports that some critical artery branches (extending from the ascending and deep cervical arteries and the

radicular artery) are located in the posterior aspects of the foramen—which can be injured when

conducting routine fluoroscopy-guided CNRB.

P18

Changes in blood glucose levels in diabetic patients following variable corticosteroid injections

Woo-Yong Shin1*†, Bong-Yeon Lee1, Min-Ji Ahn1, Yu-Ri Choe 1, Seo-Ra Yoon1

Kwangju Veterans hospital, Department of Rehabilitation Medicine1

Objective Steroid injections are used to treat a variety of pain conditions with the goal of decreasing pain. Typically we thought that steroids injection risks increasing blood glucose levels, especially diabetic patients. The aim of this study is to quantify diabetic patients’ change in blood glucose levels after variable steroid injection and to assess which patient-level risk factors may predict an increase more in blood glucose levels. Subjects and method Twenty diabetic patients who receiving a variable steroid injection were included in this investigation. The typical normal morning fasting glucose and most recent hemoglobin A1c (<3months), age, injection site, variant patients’ factor was recorded for each patient. After injection, patients were contacted daily to confirm their fasting morning glucose level for 7 days post-injection. Results There was a significant increase in fasting blood glucose levels following injection limited to post-injection days 1 and returned to near baseline levels around post-injection days 2. Higher hemoglobin A1c level and older age was significantly correlated with a rise in fasting blood glucose level 1day following injection while fasting glucose level checked before injection did not predict correlated. There is a significant rise in fasting blood glucose level post-injection days 1 in lumbar region steroid injection than limb joint steroid injection. Conclusion Patients with uncontrolled blood glucose were more likely to experience a rise in fasting glucose level on post-injection. So we advise caution in higher HbA1c and older age patients when considering steroid injection if glucose levels have been acutely unstable in the days preceding injection.

P19

The efficacy of sustained releasable PDGF-microsphere for the treatment of rotator cuff tendinopathy

Seok Kang1*†, Sung Eun Kim2, Joon Shik Yoon1, Seung Nam Yang1

Korea University Guro Hospital, Department of Rehabilitation Medicine1, Korea University Guro Hospital, Department of Orthopedic Surgery and Rare Diseases Institute2

Introduction Degeneration as well as healing of the rotator cuff can be occurred in three stages: (1) inflammatory phase, (2) repairing phase and (3) remodeling phase. Platelet-derived growth factor (PDGF) plays a significant role in promoting chemotaxis, cell proliferation, extracellular matrix (ECM) production, surface integrin expression, and revascularization in fibroblasts. Previous studies demonstrated that PDGF treatment improved the biochemical, structural, and biomechanical properties in animal of tendon or ligament healing. In this study, porous microspheres (PMSs) were fabricated by a fluidic device. To impregnate PDGF on PMSs, heparin-dopamine (Hep-DOPA) was anchored on PMSs. PDGF was impregnated on Hep-PMSs. The effects of PDGF/Hep-PMSs were demonstrated by tissue amelioration in collagenase-induced rotator cuff rabbit model after local injection of PDGF/Hep-PMSs. Methods To create collagenase-induced rotator cuff tendinitis in rabbits, rabbits undergone anesthesia with isoflurane. Under anesthetization, 50 μL of collagenase type I [50 mg/mL dissolved in PBS (pH 7.4)] was injected into near the supraspinatus tendon. Rabbits were euthanized at 4th weeks after injections of PMSs, PDGF/PMSs, PDGF/Hep-PMSs, and PDGF solution for further analysis. Experimental groups were divided into six treatment groups: (I) control (no treatment), (II) Col (I) (collagenase treatment), (III) Col (I) + PMSs, (IV) Col (I) + PDGF, (V) Col (I) + PDGF/PMSs, and (VI) Col (I) + PDGF/Hep-PMSs. To demonstrate the anti-inflammatory effects after each group injection, pro-inflammatory cytokines (MMP-3, MMP-13, COX-2, IL-1, IL-6, and TNF-α) and anti-inflammatory cytokines (IL-4, IL-10, and IL-13) were measured at 4th weeks after injection of each group and PDGF. To confirm the tendon healing of rotator cuff tendinitis after PDGF/PMSs injection, collagen contents on rotator cuff were measured by hydroxyproline assay kit. For histological evaluations, the specimens isolated from rabbit were fixed. The sliced tissue samples were stained with Masson’s trichrome to confirm the rotator cuff healing. Results In the tendons injected with PDGF as a positive control, some collagen fibers could be showed. Moreover, collagen fibers seemed to be better organized in the PDGF/PMSs-injected tendons compared with PMSs. Furthermore, collagen fibers were neater and much more aligned in the PDGF/Hep-PMSs-injected tendons. PDGF/Hep-PMSs not only markedly decreased mRNA levels of pro-inflammatory cytokines (MMP-3, MMP-13, COX-2, IL-1, IL-6, and TNF-α) but also significantly increased mRNA levels of anti-inflammatory

cytokines (IL-4, IL-10, and IL-13) in tendon tissues. PDGF/Hep-PMSs also provide improved tendon amelioration by increasing the collagen content. Conclusion PDGF-impregnated Hep-PMSs are a promising therapeutic injectable material to control the degenerative tendon disorder and the pain associated with it.

Masson’s trichrome staining 5 weeks after collagenase [Col (I)] injection into tendon tissues, and 4 weeks

after injection of PMSs, PDGF, PDGF/PMSs, and PDGF/Hep-PMSs. Groups were divided into six treatment

groups: (a) control (no treatment), (b) Col (I) (collagenase treatment), (c) Col (I) + PMSs, (d) Col (I) + PDGF, (e)

Col (I) + PDGF/PMSs, and (f) Col (I) + PDGF/Hep-PMSs.

The relative mRNA levels of pro-inflammatory cytokines, including: : (a) MMP-3, (b) MMP-13, (c) COX-2, (d)

IL-1, (e) IL-6 and (d) TNF-α in tendon tissues from a collagenase-induced rotator cuff tendinitis rabbit model

in each group at 4th weeks after injections of PMSs, PDGF, PDGF/PMSs, and PDGF/Hep-PMSs. Each mRNA

expression level was determined using real time-PCR analysis. Error bars represent the means ± SDs (n = 5).

(*P < 0.05 and **P < 0.01).

The relative mRNA levels of pro-inflammatory cytokines, including: (a) IL-4, (b) IL-10, and (c) IL-13 in tendon

tissues from a collagenase-induced rotator cuff tendinitis rabbit model in each group at 4th weeks after

injections of PMSs, PDGF, PDGF/PMSs, and PDGF/Hep-PMSs. Each mRNA expression level was determined

using real time-PCR analysis. Error bars represent the means ± SDs (n = 5). (*P < 0.05 and **P < 0.01).

P20

Add-on Effect of Aerobic Exercise in Patients with Ankylosing Spondylitis

Jinyoung Park1*, Hye Won Kim2†, Doyoung Kim1, Jung Hyun Park1, Min-Chan Park3†

Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Rehabilitation Medicine1, Hospital Medicine Center, Seoul National University Bundang Hospital, Department of Internal Medicine2, Yonsei University College of Medicine, Seoul, South Korea, Division of Rheumatology, Department of Internal Medicine3

Introduction Ankylosing spondylitis (AS) is a chronic inflammatory disease involving axial skeletal system, peripheral joints, and non-articular structures. Unlike stretching exercise, the effect of aerobic exercise in patients with AS is not well known, and there is a lack of detailed protocols of aerobic exercise. We aimed to identify the additional benefits of aerobic exercise for stretching exercise in patients with AS. Methods 1) Patients This prospective study recruited 34 patients classified as AS according to the 1984 modified NY criteria or the ASAS classification criteria between the age of 20 and 60 years. 16 patients were allocated for stretching and aerobic exercise (Group A), and 18 patients for stretching only (Group B). 2) Exercise Education To educate precisely, we developed an exercise protocol of written instruction with photographic guides. The AS school was held twice inviting each group in different day. After informing the general disease concepts by a rheumatologist, the instruction of the exercise prescription was done by a physiatrist and a physical therapist. The precise exercise protocol is described in Table 1. 3) Functional Outcome As functional outcomes, 11 scales are surveyed or examined before and after 12 weeks of home exercise; total and nocturnal pain with Visual Analogue Scale (VAStotal and VASnocturnal), Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Routine Assessment of Patient Index Data (RAPID3), Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL), Fatigue Severity Scale (FSS), Jenkins Sleep Evaluation Questionnaire (JSEQ), and The Brief Illness Perception Questionnaire (BIPQ). Bath Ankylosing Spondylitis Metrology index (BASMI) was examined before (0), and 30 minutes and 3 months after exercise. 4) Statistical Analysis Basic characteristics were analyzed using T test or Fisher’s exact test. The changes in functional scales at 12 weeks compared to initial point were analyzed by T test and repeated-measures ANOVA. Results Basic characteristics showed no significant differences between two groups (Table 2). The changes of all 11 scales at 12th weeks did not show significant difference between the groups; ΔVAStotal (P=0.59), ΔVASnocturnal (P=0.95), ΔASDAS (P=0.86), ΔBASDAI (P=0.84), ΔRAPID3 (P=0.61), ΔBASFI (P=0.49), ΔASQoL (P=0.82), ΔFSS (P=0.17), ΔJSEQ (P=0.86), ΔBIPQ (P=0.50), ΔBASMI (P=0.19). However, ΔBASMI and sub-scores of lateral lumbar

flexion (P<0.01), tragus-to-wall distance (P=0.02), modified Schober test (P=0.03) had significant cumulative exercise effects (Table 3). Conclusion Aerobic exercise in patients with AS did not show a significant add-on effect to stretching alone. However, with limitations of small sample size and not considering the cardiopulmonary effects, further study with larger data would be required.

Table 1. Exercise prescriptions of the two groups.

Table 2. Basic characteristics of the two groups.

Table 3. Bath Ankylosing Spondylitis Metrology Index (BASMI) of the two groups.

P21

Clinical assessment for diagnosis of sarcopenia in patients with stroke

Ho Joong Jung1*, Yong Min Lee2, Minsun Kim3, Kyeong Eun Uhm4, Bo-Ram Kim5, Jongmin Lee6†

Konkuk University Medical Center, Department of Rehabilitation Medicine1, Konkuk University Medical Center, Department of Rehabilitation Medicine2, Konkuk University Medical Center, Department of Rehabilitation Medicine3, Konkuk University Medical Center, Department of Rehabilitation Medicine4, Gyeong-in Rehabilitation Center Hostpital, Department of Rehabilitation Medicine5, Konkuk University Medical Center, Department of Rehabilitation Medicine6

Background Sarcopenia is characterized by decreased muscle mass, muscle strength, and physical performance. The current diagnostic assessments include muscle mass measurements (dual X-ray absorptiometry or bioimpedance analysis), handgrip strength for muscle strength and usual gait speed for physical performance. However, clinical diagnosis of sarcopenia is limited in stroke patients due to stroke-related hemiplegia. We investigated the alternative variables to assess the sarcopenia in stroke patients. Methods Forty patients (17 male, 23 female; mean age of 65.5 years) with first ever ischemic or hemorrhagic stroke were included. Patients with history of neuropathy or myopathy, and severe medical comorbidities were excluded. Muscle mass was measured by the Skeletal Muscle Index(SMI) of bioelectrical impedance analysis with InBody S10, and sonographic muscle thickness measurement of vastus intermedius (VI), rectus femoris (RF), tibialis anterior (TA), gastrocnemius, and biceps brachii (BB) muscles. Muscle strength was assessed by handgrip strength and Medical Research Council (MRC) sum score. Physical performance was measured by 4-m gait speed, 6-minute walk test (6MWT), and Berg Balance Scale (BBS). Correlations between each assessment in three categories were analyzed. Results In terms of muscle mass, the SMI correlated with all of the affected and unaffected muscle thickness. In particular, the sonographic muscle thickness of TA (r=0.794, p<0.01) muscle showed the highest correlation coefficients among the muscles. Regarding muscle strength, the MRC sum score correlated with the affected (r=0.373, p<0.01) and unaffected (r=0.398, p<0.01) handgrip strength. For physical performance, BBS correlated with the 6MWT (r=0.832, p<0.01) and 4-m gait speed (r=0.833, p<0.01). Conclusion These results suggest that the MRC sum score and BBS could be alternative assessments for handgrip strength and usual gait speed for the diagnosis of sarcopenia in stroke patients. In addition, TA muscle could be used for the sonographic muscle thickness

measurement. Further study is needed to determine the cutoff values for MRC sum score, BBS, and muscle thickness measurements for the diagnosis of sarcopenia.

P22

Association Between Skeletal Muscle Mass and Cardiorespiratory Fitness in Elderly Men

Seung-Hyun Boo1*, Min Cheol Joo1, Jeong Mi Lee2, Seung Chan Kim3, Young Mi Yu1, Min-Su Kim1†

Wonkwang University School of Medicine & Hospital, Department of Rehabilitation Medicine1, Wonkwang University School of Medicine & Hospital, Department of Preventive Medicine2, Pukyong National University, Department of Statistics3

Aim Sarcopenia reduces physical ability and cardiorespiratory fitness, leading to poor quality of life. We investigated the relationship between skeletal muscle mass and cardiorespiratory fitness in elderly men. Methods We assessed 102 community-dwelling men over 60-year-old. Appendicular skeletal muscle mass was determined using bioelectrical impedance analysis, and the skeletal muscle mass index was calculated as appendicular skeletal muscle mass divided by the square of height. Subjects with an skeletal muscle mass index less than 7.0 kg/m2 were included in the sarcopenic group, as recommended by the Asian Working Group for Sarcopenia. To investigate cardiorespiratory fitness parameters, a cardiopulmonary exercise test was performed using the Bruce protocol. Cardiorespiratory fitness parameters were subdivided into aerobic capacity, cardiovascular response, and ventilatory response. Results Of the 102 subjects, 15 (14.7%) were included in the sarcopenic group. There was a positive correlation between skeletal muscle mass index and maximal oxygen consumption (p<0.05), and between skeletal muscle mass index and ventilatory threshold (p<0.05). Additionally, maximal oxygen pulse, which is the maximal oxygen consumption divided by maximal heart rate, was significantly correlated with skeletal muscle mass index (p<0.05). Moreover, maximal oxygen consumption and maximal oxygen pulse showed significant differences between the two groups (p<0.05, all). In multiple linear regression analyses, the factor related to maximal oxygen consumption was skeletal muscle mass index (p<0.05) and that related to maximal oxygen pulse was also skeletal muscle mass index (p<0.05). Conclusion This study demonstrated that skeletal muscle mass might be closely associated with cardiorespiratory fitness.

P23

Predictive value of pharyngeal width at rest (JOSCYL Width) for aspiration in elderly people

HoYoung Lee1*, Kwang-Ik Jung1, Woo-Kyoung Yoo1, Suk-Hoon Ohn1†

Hallym University College of Medicine, Department of Physical Medicine and Rehabilitation1

Introduction Dysphagia in elderly people without brain disorder is mostly due to weakness of pharyngeal muscle contraction. The pharyngeal width determined by the strength of pharyngeal constrictor muscle might be an indicator of aspiration. In this study, we used a simple non-invasive technique to characterize the anatomical changes associated with pharyngeal weakness. Lateral neck roentgenogram, video fluoroscopic swallowing study (VFSS) and dysphagia scales (Penetration Aspiration scale, PAS; Dysphagia Outcome and Severity Scale, DOSS) were used and we determined if the average of pharyngeal width (named as JOSCYL Width) has a value of the index indicating the possibility of aspiration. Methods Lateral cervical spine x-rays at rest were obtained from 33 participants aged 65 and over suffering from swallowing difficulty without brain disorder and 33 healthy volunteers aged 65 and over with no swallowing difficulty. Before examination, one physician evaluated age, gender, body mass index (BMI) and neck circumference of the participants. Two physicians measured the pharyngeal width on the lateral cervical spine x-ray. JOSCYL width was defined as the mean value of two pharyngeal widths measured at mid-oropharynx (A) and lower oropharynx (B) (figure 1). A video fluoroscopic swallowing study (VFSS) was performed and the Penetration-Aspiration scale (PAS) and the Dysphagia Outcome and Severity Scale (DOSS) were determined as objective parameters of dysphagia. Independent t-test and chi-square test were used for analyzing demographic data. The correlation between the JOSCYL width and the scores of PAS and DOSS was analyzed in the participants with swallowing difficulty and control group using Spearman correlation analysis. A receiver operating characteristic (ROC) was performed on JOSCYL width. Results The ages of dysphagia group ranged between 66 and 89 years old (with a mean age of 78.69 ±7.1 years) and control group ranged between 66 and 92 years old (with a mean age of 77.66±8.9 years). Through Independent t-test and chi square test, age, gender, BMI and neck circumference between both groups was not statistically significant. The JOSCYL Widths of the dysphagia group (19.2 ± 5.0 mm) was larger than those of the control group (15.0 ± 3.4 mm; p<0.05). The correlation between the JOSCYL Width and the severity of dysphagia was significant for dysphagia group (p<0.05). The optimal cutoffs for predicting aspiration were 20.01mm in the dysphagia group.

Conclusion The JOSCYL Width was wider in elderly people with swallowing difficulty than healthy elderly people and well correlated with the severity of dysphagia. Compared to the current dysphagia assessment tools, the JOSCYL width is easy and precise tools to predict dysphagia. So, it can be a new indicator for predicting aspiration in elderly with swallowing difficulty.

Fig. 1

P24

Comparing Range of Motion of Hip, Knee and Ankle Joints between Healthy 20s-30s and Elderly Korean

HaNa Jung2*, Il-Young Jung1, Jong-Hyun Park2, KangHee Cho1,2†

Chungnam National University, Department of Rehabilitation Medicine, School of Medicine1, Chungnam National University, Institute of Biomechanical Engineering2

Objective To investigate the difference of range of motion (ROM) of lower extremities according to age Subject & Method Total 578 healthy people participated in the study. Participants are classified into 2 groups by age. One is between 20 to 30 years (n=318, mean age 26.0±6), and the other is over 65 years (n=260, mean age 71.8±4). People who have neurologic disease, musculoskeletal problem, history of lower extremity surgery, pain of lower extremity and low back pain or whose body mass index are more than 30 were excluded. All the subjects had a radiographic examination of the lower extremity, among which the elderly whose Kellgren-Lawrence grade was more than 3 were excluded. Korean ROM Standard Protocal (KRSP) was used in measuring ROM and pushing force of 0, 2, 4 kgf in elderly people. One examiner measured the active and passive ROM of hip, knee and ankle joints by Dualer IQ Inclinometers (J-tech, USA) and applied pushing force by using MicroFET2 (HOGGAN, USA). ROM of hip, knee and ankle joints were measured according to change of force at supine position (hip flexion), side-lying position (hip abduction, adduction), prone position (hip extension, internal rotation, external rotation, knee flexion), prone position with knee flexion 90˚ (ankle inversion, eversion, dorsiflexion, plantar flexion) and prone position with knee extension 0˚ (ankle dorsiflexion, plantar flexion). The ROM was measured 3 times and the average value was used. Result This study found a difference between the ROM of lower extremities in 20s-30s and elderly people. The results showed a marked lower active and passive ROM of hip extension, abduction, internal rotation, external rotation, knee flexion, ankle eversion, dorsiflexion and plantar flexion in elderly people than the young people (p<.001). The active ROM of hip flexion was also lower in elderly (p<.01). However, the result of active and passive ROM of ankle inversion was higher in the elderly (p<.001) and in ROM of hip adduction, there were no statistically significant difference between these groups. Conclusion Overall, the ROM of lower extremities in the elderly were lower than the young except for the case in ankle inversion.

Fig 1. Comparing ROM of (a)Hip internal rotation, (b)Knee flexion, (c)Ankle inversion between Healthy 20s-

30s and Elderly Korean

P25

Gait Analysis of Idiopathic Parkinson’s Disease and Other Parkinsonism : Preliminary study

Hye Won Jeong1*†, Soo Jeong Han1, Ji Young Yun1

Ewha Womans University, Department of Rehabilitation Medicine1, Ewha Womans University, Department of Neurology2

Objective It is a challenge to distinguish Idiopathic Parkinson’s Disease (IPD) since it shares symptoms with a number of other diseases commonly referred to as Parkinsonism such as atypical and secondary Parkinsonism, despite differences in etiology and course of treatment. There is growing interest in having objective assessment of disease using technology-based devices that provide unbiased measurements which can be used in clinical practice. The aim of this study was to compare and quantify spatiotemporal and kinematic gait parameters obtained by gait analysis (GA) in a group of IPD patients compared with parkinsonism other than IPD. Material and methods Patients who visited the center of neurology or rehabilitation with feature of parkinsonism were recruited from Single University Hospital. We identified patients with the most convincing diagnosis of IPD or parkinsonism other than IPD at hospital discharge by neurologic specialists of Parkinsonism. The level of functional disability was determined using the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Hoehn and Yahr (H&Y) scale by neurologist. Gait analysis(GA) was performed on a force platform (Zebris Medical GmbH, Isny, Germany). The spatiotemporal parameters were estimated from the vertical pressures. All the experiments were conducted while the patients were in an “OFF” state. The subjects stood barefoot on the force platform for a few seconds and initiated gait at their own pace. One or two practice trials were performed before the experimental trials. Student t-test and Mann-Whitney test were conducted in the comparison of the gait parameters between IPD and Parkinsonism other than PD. All statistical analyses were performed using SPSS (SPSS, Chicago, IL). A p value≤ 0.05 was considered statistically significant. Result A total thirty-five patients were recruited. We assessed fifteen IPD patients and twenty other parkinsonism patients. There was demographic data of IPD patient and other parkinsonism patient in terms of sex, age, UPDRS motor score and H&Y score in Table 1. IPD group and other parkinsonism patient did not differ statistically in terms of step length of each side, stride length, step width, stance phase of each side, swing phase of each side, double stance phase, cadence, anterior/posterior position of COP or lateral symmetry. Although, in other parkinsonism group, the difference in step length between the right and left feet was significantly higher (p < 0.05), as shown in Table 2. Conclusion This study shows that the difference of spatiotemporal parameter between IPD and parkisonism other than IPD using GA and there was statically significant difference in

difference of step length, which is higher in other parkinsonism. The result supports that conducting the gait analysis aid to distinguish IPD from other parkinsonism and can be helpful to decide approach of treatment or predict prognosis. Table 1. demonstrates demographic data of IPD patient and other parkinsonism patient in terms of sex, age,

UPDRS motor score and H&Y score.

Table 2. demonstrates spatiotemporal parameters of IPD patient and other parkinsonism patient by gait

analysis. The difference in step length between the right and left feet was significantly higher in

parkinsonism other than IPD group.

P26

Swallowing Dysfunction of the Elderly in Intensive Care Unit and Non-Intensive Care Unit

Da-Sol Kim1,2*, Gi-Wook Kim 1,2, Yu Hui Won1,2, Sung-Hee Park 1,2, Myoung-Hwan Ko 1,2, Jeong-Hwan Seo 1,2†

Chonbuk National University Hospital, Department of Physical Medicine and Rehabilitation1, Chonbuk National University Hospital, Research Institute of Clinical Medicine 2

Introduction The aim of this study was to clarify causes of swallowing dysfunction of the elderly without previous neurologic lesion in brain images or electrophysiological examinations via videofluoroscopic swallowing study (VFSS) and its associated factors such as albumin, body mass index (BMI) and intensive care unit (ICU) admission. Methods Medical records of elderly patients (>65 years) with dysphagia symptoms who were hospitalized due to respiratory disorders such as pneumonia or chronic obstructive pulmonary disease in Regional Pulmonary Center and consulted to Rehabilitation Department because of dysphagia symptoms from January 2014 to September 2017 were reviewed. Patients who had been diagnosed with stroke, Parkinson’s disease, motor neuron diseases such as amyotrophic lateral sclerosis, and previous history of cervical spinal operation were excluded. Swallowing function was evaluated by VFSS and serum albumin, body mass index (BMI), use of nasogastric tube, prevalence of pneumonia in chest computed tomography (CT) were evaluated. Results In total, 30 elderly patients with no underlying brain lesion and neurological disorder were included, of which 13 patients were treated in ICU. Patients in ICU group showed lower serum albumin level and more frequent use of nasogastric tube (3.0±0.2, P=0.015 and 76.9%, P=0.025) compared with patients in non-ICU group. The prevalence of pneumonia in chest CT were 92.3% in ICU group and 70.6% in non-ICU group, but the data were not enough to show statistical significance. For comparison of Penetration-Aspiration Scale (PAS) between two groups, the ICU group showed higher score in 2cc fluid (4.5±2.9, P=0.025), but PAS in other food materials did not show statistical significance. Conclusions In conclusion, the ICU group observed more severe aspiration, particularly fluid, although they did not have underlying brain lesion and neurologic disorder. Therefore, older patients who have been hospitalized in ICU should be carefully monitored swallowing dysfunction and proper rehabilitation would be necessary.

P27

Findings of videofluoroscopic swallowing study (VFSS) in elderly patients with aspiration pneumonia

Joo Young Ko1*, Jung Keun Hyun1,2, Tae Uk Kim1, Seo Young Kim1, Seong Jae Lee1†

Dankook University Hospital, Department of Rehabilitation Medicine1, Dankook University, Department of Nanobiomedical Science & BK21 PLUS NBM Research Center for Regenerative Medicine2

Objective Elderly patients have a higher risk of aspiration pneumonia even without dysphagia. Swallowing process might be affected by senile changes but those changes have not fully investigated yet. This study is designed to delineate the changes in elderly patients with aspiration pneumonia based on the findings of videofluoroscopic swallowing study (VFSS). Method Eighteen patients diagnosed as aspiration pneumonia, who underwent VFSS were included. Those who have direct causes of dysphagia such as recent brain disorders, cranial nerve palsy or structural abnormalities were excluded. Baseline characteristics and VFSS findings including American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) score, Penetration-aspiration scale (PAS), oral transit time (OTT), pharyngeal delay time (PDT), pharyngeal transit time (PTT) were reviewed retrospectively. Results Mean age of subjects was 72.56±11.05. Fourteen patients had one or more systemic disease (e.g. diabetes mellitus, hypertension, chronic obstructive pulmonary disease, or heart failure). In VFSS finding, mean ASHA NOMS score and PAS were respectively 3.00±2.24, 5.22±3.11. Time parameters of oral and pharyngeal phase were generally delayed compared with normal (OTT was 4.99±6.68 sec (normal≤1.50 sec), PDT was 2.73±3.23 sec (normal<0.36 sec), and PTT was 4.03±3.88 sec (normal<1.00 sec)), respectively. Conclusion The elderly patients with aspiration pneumonia show delay in oral and pharyngeal phases although they have no disorders directly causing dysphagia. The results suggest that higher risk of aspiration pneumonia in elderly probably originates from delay in swallowing process.

P28

The treatment with repetitive transcranial magnetic stimulation on non-lesional focal epilepsy

Seong Hoon Lim1*†, Yeonji Yoo1, Sung Chul Lim2

Department of Rehabilitation Medicine, Department of Rehabilitation Medicine1, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Department of Neurology2

Purpose Repetitive transcranial magnetic stimulation(rTMS) is a non-invasive technique that changes excitability of different cortical areas. Our aim is to evaluate the number and duration of seizures in patients with focal epilepsy during and after 0.5 Hz-rTMS. Methods Patient population Three patients with focal epilepsy were studied whose electrical sources of paroxysmal activity in neocortical regions were determined. They received standard pharmacological treatment without modification from at least 1 month before the study started. Study design rTMS was carried out at baseline, intervention and follow-up periods. The baseline period duration was 4 weeks and intervention with rTMS for 2 weeks, and follow-up period for 8 weeks. EEG analysis A high-resolution 120 channels-EEG was used. The epileptic focus was determined with current source analysis of paroxysmal activity by sLORETA. Current sources are restricted to brain parenchyma by the use of a mask that prohibits solutions where the mask is zero, i.e., in the CSF (Figure 1). Repetitive transcranial magnetic stimulation rTMS session at 0.5 Hz was carried out on the epileptogenic zone with total of 900 pulses delivered at 100% intensity of the resting motor threshold(RMT) during 2-weeks. Using neuronavigation system improved the targeting of the epileptic foci (Figure 1). Results During the baseline, three patients had seizures, 7.25, 3.25, 4 times per week. In patient number 2 and 3, this frequency decreased during the intervention period to 1, 0.5 times respectively, which means 69%, and 87% reduction. During the follow-up period, this decreased to 2.13 and 1.13 times per week, corresponding to 34% and 72% decrease. (Figure 2) Conclusion We think that 0.5Hz rTMS over epileptic focus decrease the number of seizures in patients with focal epilepsy. rTMS for non-lesional focal epilepsy may be an alternative treatment for pharmoco-resistant patients.

Fig 1. Localization of the epileptic focus, using electrical source analysis with sLORETA. (A) In the right

inferior frontal region of patient number 1. A precise localization of the epileptic focus combined with

neuronavigation systems to place the coil over the head improved the targeting of the epileptic foci. (B)

Right parietal region of patient number 2. (C) Right superior frontal region of patient number 3.

Fig 2. Mean number of seizures per week during, baseline, rTMS and follow-up period.

P29

Natural history of spasticity for upper limb in patients with stroke

Kyung Eun Nam1*, Seong Hoon Lim2†, Joon Sung Kim2, Bo Young Hong2, Han Young Jung3, Ju Kang Lee4, Seung Don Yoo5, Sung-Bom Pyun6, Kyoung Moo Lee7, Kwang Jae Lee8, Hyundong Kim9, Eun Young Han10, Keong Woo Lee11

The Catholic University of Korea, Seoul St. Mary1, The Catholic University of Korea, St. Vincent’s Hospital, Department of Rehabilitation Medicine2, Inha University Medical School, Department of Rehabilitation Medicine3, Gachon University College of Medicine, Department of Rehabilitation Medicine4, Kyung Hee University College of Medicine, Department of Rehabilitation Medicine5, Korea University College of Medicine, Department of Rehabilitation Medicine 6, Cungbuk national university, , Department of Rehabilitation Medicine 7, Presbyterian Medical Center, Seonam University College of Medicine, Department of Rehabilitation Medicine 8, Busan Paik Hospital, College of Medicine, Inje University, Department of Rehabilitation Medicine 9, Jeju National University Hospital, Jeju National University School of Medicine, Department of Rehabilitation Medicine 10, Dong-A University College of Medicine, Department of Rehabilitation Medicine11

Introduction Spasticity is one of the major complications of stroke and commonly defined as a velocity-dependent increased in tonic stretch reflexes. Upper extremity spasticity has a significant contribution on functional impairment due to restrictions in range of motion and speed of limb movement. Severe spasticity can be deep distress, such as painful muscle spasm, to the stroke survivors. Therefore, post-stroke spasticity should always be looked for as their adequate treatment. The prevalence of upper extremity spasticity had been reported to vary from 17% to 42% and increase with time. Different risk factors associated with the development of spasticity have been suggested in various studies, including lower BI scores, degree of paresis, stroke related pain, and sensory deficits. Although there are many studies to find early predictors of upper limb spasticity, it is not clear when spasticity occurs after stroke. Therefore, we investigate the time to develop upper extremity spasticity after stroke onset and topical distribution, with nation-wide multicenter studies in South Korea. Methods This was a large-scale, multi-center, cross-sectional, retrospective clinical study from December of 2011 to November of 2014. Eight hundred sixty one subjects with post-stroke spasticity of upper limb were recruited from the Department of Rehabilitation Medicine in nation-wide 10 Hospital. Inclusion criteria are as follows: 1) spasticity, defined as grade 1 or more by modified Ashworth scale(MAS), in upper limb; 2) diagnosed first-ever ischemic or hemorrhagic stroke and evaluated within 3 months after onset. Exclusion criteria were 1) previous recruitment for study of spasticity management such as botulinum toxin; 2) recurrent stroke. We obtained demographic data, co-morbidity and brain imaging studies (MRI or CT) undertaken within 30 days after onset.

Spasticity in the upper extremity was assessed with MAS and followed up to 12 months if possible. Result The demographic characteristics of the patients are shown in table 1. The basal ganglia (42.04%), cortex (37.05%) and thalamus (8.48%) are common brain lesion mainly involved. The mean time to develop upper limb spasticity after stoke onset is 62.03 ± 118.21 days (Table2). Statistically, it shows great heterogeneity and about 16% of stroke survivors develop spasticity after 6 months from onset. At the time of diagnosis for spasticity, most patients show only a slight increase in muscle tone and severe spasticity (MAS ≥3) is observed in only 2.90%. Table 3 shows the distribution of the MAS at each of the joints. Spasticity presents in the order of elbow, wrist, finger, shoulder and slightly increases with time up to 12 months. Conclusion The time to occur spasticity of upper extremity after stroke is average 2 months and very diverse. Post-stroke spasticity can develop after 6 months from onset. Therefore, follow up examination for identification of spasticity is necessary even in the chronic state. Table 1. The demographic characteristics of the patients

Table 2. The time to develop upper extremity spasticity after stroke onset and its severity (Days)

Table 3. Topical distribution of the MAS at each of the joints

P30

BCI action observation game superiorly facilitate the MNS in patients with stroke

Hyoseon Choi1*, Hyunmi Lim2, Joon Woo Kim1, Jeonghun Ku2, Youn Joo Kang1†

Eulji Hospital, Eulji University, Department of Rehabilitation Medicine1, College of medicine, Keimyung University, Department of Biomedical Engineering2

Introduction The action observation(AO) training based on mirror neuron theory is a strategy to enhance motor performance for stroke rehabilitation. However, its use in rehabilitation has been limited because patients are easily bored and it could not sufficiently induce the recovery after stroke. The aim of this study was to investigate the effects of combined BCI- AO game on the facilitation of ipsilesional mirror neuronal system(MNS) in stroke patients. Methods We made a BCI-AO game that provides real-time BCI feedback. The degree of user’s watching was provided by flickering action video game using Entity Relationship Diagram and Steady state visual evoked potential (Figure 1, 2). Five right hemiplegic stroke patients were recruited and watched a video of repetitive grasping actions under two different conditions: 1) BCI -AO game and 2) conventional AO (without flickering and BCI feedback) game. The study was performed in following order: rest, training, and next two in a random order. To assess the facilitation of MNS, Mu rhythm (8-13Hz) of the motor cortex (C3, C4) was recorded by EEG throughout each condition. The degree of decrease in Mu rhythm power during the therapy for the rest was calculated as the log ratio of Mu(therapy) to Mu(rest). EEG was collected from 19 electrodes, using a DSI-24 (wearable sensing, San Diego, USA). Data were sampled at a rate of 128 Hz. Results The Mu rhythm power showed a suppression in both C3 and C4 in the BCI-AO game compared with conventional AO game. Mu rhythm suppression was significant in ipsilesional C3 in BCI-AO game, but not in conventional AO game (Figure 3). Conclusion This result supports that the AO-BCI game have superiority in facilitating the MNS and it could promote the recovery in patients with stroke.

Fig 1. Flickering action video. (a) frames of video clip (b) right hand’s action video clip

Fig 2. (a) EEG electrode locations (b) BCI action observation game

Fig 3. Mu rhythm suppression

P31

Prognostic factors of swallowing recovery in patients with dysphagia after ischemic stroke

JinTae Hwang1*, YongTaek Lee1, JongGeol Do1, JungSang Le1, KunWoo Kim1, KyungJae Yoon1†

Kangbuk Samsung Medical Center, Department of Rehabilitation Medicine1

Introduction Dysphagia is a common complication of stroke patients. In stroke patients, dysphagia is associated with poor long term outcome and high mortality. However, it is still difficult to evaluate the prognosis for dysphagia after stroke. Prediction of swallowing recovery can help determine alternative feeding methods and set the goal of feeding. The object of this study was to investigate the prognostic factors of swallowing recovery in patients with ischemic stroke. Material and method This is a cohort analysis of all acute ischemic stroke patients admitted from 2011 to 2017. This experiment included the patients (1) who had first acute ischemic stroke, confirmed by MRI and (2) who were observed Dysphagia Outcome and Severity Scale (DOSS) level below 5 by a video fluoroscopic swallowing study (VFSS). The DOSS is previously developed dysphagia scale based on measures obtained from VFSS. The DOSS level 7 means normal swallowing function and level 6 means swallowing function within functional limits. The DOSS levels less than 5 indicate dysphagia, and lower levels mean severe dysphagia. Follow-up VFSS was done until 1 year after stroke and discontinued if VFSS results in DOSS level 6 or 7. The covariates assessed by multivariate Cox’s proportional hazards model, which event is set by recovery of swallowing function to the DOSS level 6 or 7. For further study, age was divided into more and less than 75, 80, and 85, respectively. The DOSS level was dichotomized into more and less than 4, which may exhibit aspiration with weak or no reflexive cough. We used the Kaplan-Meier method to identify log-rank test and generate a curves for the proportion of people with recovery. Hazards ratio (HRs) for effects of aging and severity of dysphagia were calculated by Cox’s proportional hazards model. Results A total of 183 patients were included for the study and Table 1 shows the characteristics of them. Using a multivariate Cox’s proportional hazards model, it was determined that the age of onset and the initial DOSS level were significantly related to dysphagia recovery (table 2). In addition, the patients with bilateral lesions were not normalized in swallowing function. Total 41 patients (22%) recovered to normal swallowing, however patients older than 85 years did not recover to normal swallowing. The patients older than 80 years and under the initial DOSS level 4 have a significantly reduced rate of recovery (HRs 0.317, 95% CI 0.097-1.032; Log-rank p=0.044; Figure 1(A) and HRs 0.233, 95% CI 0.121-0.451; Log-rank p=<0.001; Figure 1(B)).

Conclusion The aging, severity of initial dysphagia, and bihemispheric lesion are negatively associated with recovery to normal swallowing in first ischemic stroke patients. Especially the age over 80 years and initial DOSS level under 4 are poor prognostic factors affecting swallowing recovery during 1 year after stroke. This study was supported by the fund of Minister of Education, NRF-2017R1D1A1B03032899. Table 1. Characteristics of patients

Table 2. Multivariate Cox's proportional hazards model for the covariates

Fig 1. Kaplan-Meier method to curves for the proportion of people with recovery;

(A) Recovery rate in people with older than 80 years compared to under 80 years and

(B) Recovery rate in people with the initial DOSS level under 4 compared to level 5

P32

Comparative study of the Swallowing Motion in Healthy Adults and Patients with Parkinson’s Disease

Woo Hyung Lee1*, Min Hyuk Lim1, Han Gil Seo2, Hyung Seok Nam1, Yoon Jae Kim3, Byung-Mo Oh2†, Sungwan Kim1,3†

Seoul National University College of Medicine, Department of Biomedical Engineering1, Seoul National University Hospital, Seoul National University College of Medicine, Department of Rehabilitation Medicine2, Seoul National University, Interdisciplinary Program for Bioengineering3

Objective The aim of this study was to investigate the difference of the hyoid motion during swallowing between healthy adults and patients with Parkinson’s disease (PD) using functional regression analysis. Study Design Retrospective observational study. Methods Total 38 patients with PD were retrospectively reviewed and compared with 29 healthy adults. Data of the hyoid motion during swallowing was collected from videofluoroscopic swallowing study. Parameters including displacement and velocity of the hyoid motion in horizontal and vertical planes, and association between the hyoid bone and liquid bolus were analyzed using functional regression analysis. Results The significant difference between the hyoid displacements of two groups lies in the 10-18th and 30-56th percentile in horizontal plane, and the 22-32nd and 54-64th percentile in vertical plane for swallowing duration. The significant difference between the hyoid velocity in each group lies in the 1-6th, 19-34th, and 49-68th percentile in horizontal plane, and the 44-55th and the 63-70th percentile in vertical plane for swallowing duration. Subgroup analysis for the hyoid displacement showed that there was significant difference only for horizontal displacement in 58-71st percentile of swallowing duration between young and old healthy adults. Healthy adults and PD patients showed significant association between the horizontal displacements of the hyoid bone with the vertical displacement of the liquid bolus lies in the 38-97th percentile and in the 45-85th percentile of swallowing duration, respectively. Significant association between the vertical displacements of the hyoid bone with the vertical displacement of the liquid bolus lies in the 37-56th percentile of swallowing duration, and between the vertical velocity of the hyoid bone and horizontal velocity of the bolus lies in the 20-83th percentile of swallowing duration.

Conclusion This study revealed that the hyoid kinematics during swallowing in PD patients showed different spatiotemporal characteristics compared to healthy adults in terms of displacement, velocity of the hyoid bone in horizontal and vertical planes, and association between the hyoid bone and liquid bolus. Functional regression analysis can be a good methodology to analyze time series data of swallowing motion and to investigate features of swallowing impairment.

Results of functional regression analysis for horizontal and vertical displacement of the hyoid bone.

Results of functional regression analysis for horizontal and vertical velocity of the hyoid bone.

Estimated regression coefficient functions for the hyoid and bolus displacements in healthy adults (A-D) and

patients with Parkinson's disease (E-H) using the functional regression model.

P33

TIME-COURSE AND EVOLUTION OF UPPER LIMB SPASTICITY DURING THE ONE YEAR FOLLOWING FIRST-EVER STROKE

Jung Han Young1*†, Pyun Sung Bum 1, Yoo Seung Don 1, Han Eun Young1, Lim Seong Hoon 1, Lee Ju Kang 1, Lee Kyoung Moo 1, Lee Kyeong Woo 1, Kim Hyun Dong 1, Lee Kwang Jae 1

Inha University Hospital, Department of Rehabilitation Medicine1, Korea University Anam Hospital, Department of Rehabilitation Medicine2, Kyung Hee University Hospital at Gangdong, Department of Rehabilitation Medicine3, Jeju National University Hospital, Department of Rehabilitation Medicine4, The Catholic University of Korea St. Vincent`s Hospital , Department of Rehabilitation Medicine5, Gachon University Gil Medical Center, Department of Rehabilitation Medicine6, Chungbuk National University Hospital, Department of Rehabilitation Medicine7, Dong A University Hospital , Department of Rehabilitation Medicine8, Inje University Busan Paik Hospital, Department of Rehabilitation Medicine9, presbyterian Medical Center, Department of Rehabilitation Medicine10

OBJECTIVE Post-stroke spasticity (PSS) is one of functional barrier for stroke survivors. There is a need for early identification and understanding of change of PSS over time. Therefore, we want to establish the change of post stroke spasticity until 12 months from the first ever stroke onset. METHODS A multicenter medical record review for incidence of spasticity at the first detection time, 3, 6 and 12 months after the first ever stroke at 10 university hospitals. Except for 186 stroke subjects who lacked medical records on spasticity, 814 stroke subjects with spasticity (454 cerebral infarct and 360 cerebral hemorrhages) were completely reviewed (Fig.1) (Table 1). Main outcome measures were change of post stroke spasticity (PPS) at the elbow, and wrist in hemiplegic upper limb measured by the Modified Ashworth Scale (MAS). RESULTS The 1st detection time (median value) and degree of spasticity in all stroke subjects were 1.26 / 30.5days in infarction and 1.35 / 42.0days in hemorrhage, respectively (p<0.01) (Table 2). PPS had changed from at the first detection of spasticity to at 3, 6 and 12 months in hemiplegic elbow (1.16, 1.29, 1.54, 1.82) and wrist (1.23, 1.30, 1.47, 1.84), respectively, but there were no significantly difference between elbow and wrist (p>0.05)(Table 3). In subjects with cerebral infarction, the incidence of spasticity was higher at cerebral cortex, basal ganglia, pons, thalamus, thalamus, medulla, and midbrain in order. However, the order of incidence in those with cerebral hemorrhage was basal ganglia, cerebral cortex, thalamus, pons, and cerebellum (Table 4). In the supratentorial lesion, more severe PPS was developed and aggravated over time (Table 5). For management of PPS, Physiotherapy and occupational therapy were the most basic

treatments, and other treatments were antispastic oral agents, botulinum toxin, and orthosis in order (Table 6, 7). Conclusion Post-stroke spasticity in upper limb shows different incidence and the first detection time between types of stroke, and tends to deteriorate over time, especially in cerebral hemorrhage and supra-tentorial lesions.

Fig.1 Flow diagram for the subjects with spastic upper limb

Table 2 Time course and distribution of spasticity at hemiplegic elbow flexor muscles

Table 7. Different modalities to manage spasticity in subjects for hemiplegic elbow flexor muscles

P34

Lesions Responsible for Visual Perception in Post-stroke Patients

Hyun Im Moon1*†, Hyo Jeong Lee1, Je-shik Nam1

Bundang Jesaeng Hospital, Department of Rehabilitation Medicine1

Introduction Visual perception (VP) is a process that involves ‘visual acceptance’ and ‘visual cognition’ through interaction between multiple areas in the human brain. About 35-75% of patients with brain damage have particular impairments in VP that influence the activities of daily living. We aimed to clarify the clinical characteristics that affects on VP and elucidate the lesion location correlated with impaired VP such as visual discrimination, form consistency, visual short term memory, visual closure, spatial orientation assessed with 3rd version of motor-free visual perception test (MVPT-3). Methods We reviewed 91 patients with stroke. Clinical assessments such as Korean version of Mini-mental status exam (K-MMSE), MVPT-3, functional independence measure (FIM) were used to evaluate the impairment and limitation of patients after stroke. The patients were divided into 2 groups according to lesioned hemisphere, and we analyzed the differences in characteristics such as demographic factors, lesion factors, cognitive function, and visual perception. Regression analyses were performed to examine the predictors of impaired VP. Lesion location and volume were measured on brain magnetic resonance images. We generated statistic maps of lesions related to impaired VP in swallowing using voxel-based lesion symptom mapping (VLSM). Result The group of patients who have right hemispheric lesion had significantly low VP function, especially in subscore of visual discrimination and visual short-term memory. Also, in a regression model, impaired VP was predicted with low K-MMSE, age, and lesioned hemisphere. Using VLSM, we found the lesion location to be associated with impaired VP after adjusting for age and K-MMSE score. The results showed a lesion pattern with predominant distribution in the right parietal lobe and deep white matter. Conclusion Impaired VP in post-stroke patients was not negligible clinically. Patients’ age and cognitive impairments affect the result of VP test. Even when adjusting it, we found a trend that the lesion responsible for impaired VP was located in the right parietal lobe and deep white matter. It confirms the right hemispheric dominance for VP using VLSM. The deficits in white matter lesion might be related to disconnection of fibers.

Fig 1. Lesion overlay map of 91 patients. Lesion overlay map of 91 patients showing bilateral coverage of

most of the hemispheres. Lesions appear to be uniformly distributed in both hemispheres.

Table. 1. Predictors of MVPT score using regression analysis

Fig 2. Lesion patterns associated with low MVPT score. Voxel-based lesion symptom mapping analysis shows

the relationship between MVPT score and brain lesions. Only voxels significant at p < 0.05 FWE corrected,

controlling age, cognitive function assessed with K-MMSE as nuisance covariates, are color-coded, ranging

from red to yellow. Numbers are the z-coordinates of the MNI space, with the patient’s right hemisphere on

the left side of the figure.

P35

Correlation of swallowing function with bilateral diaphragm movement in hemiplegic stroke patient

Ra Yu Yun1*, Yong Beom Shin1, Eun Gyeom Cha1, Ho Eun Park1, Jin A Yoon1†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction Stroke Patients with breathing difficulty may have swallowing difficulty because of brief apnea occurring in swallowing process. The objective of this study was to record bilateral diaphragm movement and swallowing function in stroke patients using fluoroscopy at the same time. To identify the correlation of severity of dysphasia with motor function of hemiplegic side, and bilateral diaphragm movement in stroke patients. Methods This was a prospective cross-sectional study that assessed inpatients diagnosed as hemorrhagic or ischemic stroke who were referred to rehabilitation department, Pusan University Hospital. 60 subjects who have been diagnosed as stroke and had been requested for dysphagia evaluation were initially enrolled. Finally, 47 patients (28 men, 19 women, Age 66.4 ± 12.8) satisfied our inclusion criteria and were included in the study. Video fluoroscopic swallowing study was performed to evaluate patients’ swallowing function.. Penetration aspiration scale (PAS) scale was assessed to grade the depth of airway invasion during video fluoroscopic swallowing evaluation Patients were divided into two groups according to the PAS scale: 1 to 5 were considered as normal, and 6 to 8 were considered as impaired. Diaphragmatic movement was measured by peak to peak distance during spontaneous breathing and forced deep respiration in supine position. Spearman correlation analysis was used to confirm the correlation between swallowing function with diaphragm movement. Mann-Whitney test was used to investigate compare the diaphragm movement between the two groups after dividing into two groups using the PAS scale. A p-values <0.05 were considered to indicate statistical significance. Results We found a relationship between the decreased function of swallowing and breathing. There are statistically significant negative correlations between PAS with diaphragm movement of ipsilateral side during spontaneous (rho=-0.340, p=0.019) and forced breathing (rho=-0.379, p=0.009). Also there is statistically significant negative correlation between PAS with diaphragm movement of contralateral side during forced breathing (rho=-0.318, p=0.030). (Figure 1). We divided the two groups according to the amount of residue and confirmed the diaphragm movement difference between the two groups. There are statistically significant difference of diaphragm movement between two groups, divided by amount of residue, during forced breathing in ipsilateral side (Mann-Whitney U=172.5, p=0.028) (Table 1).

Conclusion In this study, we demonstrated that the extent of diaphragm movement of ipsilateral side during forced and spontaneous breathing and contralateral side during forced breathing as accessed via fluoroscopic examination correlated with patients’ swallowing function. Therefore, we can predict insufficient respiration due to decreased diaphragmatic movement by evaluating swallowing function with performing VFSS of post-stroke patient.

Fig 1. Scatter plot for PAS and diaphragm movement

Table 1. Difference of diaphragm movement

P36

Potential Parameters for Wrist Accelerometer and Gyrosensor in Functional Evaluation of Stroke

Hyung Seok Nam1,2*, Woo Hyung Lee1,2, Im Jung Lee1, Han Gil Seo1, Matthew W Smuck3, Sungwan Kim2†

Seoul National University Hospital, Department of Rehabilitation Medicine1, Seoul National University College of Medicine, Department of Biomedical Engineering2, Stanford University, Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation3

Despite many studies on accelerometers and gyrosensors were performed regarding movements of upper extremity in stroke, yet there exist no standardized evaluating methods especially in terms of significant clinical relevance. In this study, we aimed to determine potential parameters and appropriate tasks that may serve as clinical outcome measures or an index, which can be measured with a single sensor on the wrist. Ten healthy volunteers and nine patients with hemiplegic stroke were recruited to perform Action Research Arm Test (ARAT) and a series of tasks representing activities of daily living (ADL). They were equipped with multiple IMU sensor based upper body motion capture system during the tasks. Acceleration values of the wrist and hand sensors in three global orthogonal directions and Euler angles of sensors in each segment of the upper limb with reference to their proximal segment sensors were measured. ARAT score and Brunnstrom stage were evaluated for all patients. Average amplitude and maximum amplitude of the movement segments, logsum and logsum per time was extracted and analyzed. Logsum was defined as integration of all displacements or changes for corresponding measurements. Of the parameters that showed significant differences in values between healthy subjects and patients and also significant correlation with clinical measures, average amplitude of forearm supination/pronation angle during ARAT domain 4 tasks demonstrated significant decline of the value in severely impaired patients compared to normal subjects (29.83%) and profound difference between severely and mildly impaired patients (48.46%). During ADL tasks, logsum per time for supination/pronation showed significant difference between severity levels (38.33%). Average amplitude of acceleration in x-axis (left-right) and z-axis (up-down) of hand and wrist sensors during ARAT tasks demonstrated a range of 45 to 62% value compared to healthy subjects, with 21.6 to 35.1% difference along the severity spectrum. Although accurate measurement of upper extremity movements with single wrist sensor may not be possible, specific parameters which are available from a wrist-worn sensor may play a significant role in simple or serial functional evaluation as an important predictor of clinical outcome measures.

Average amplitude angles of joint movement segments during Action Research Arm Test tasks are shown by

Brunnstrom stages.

P37

The Differential Effects of Repetitive Magnetic Stimulation on Gene Expression in neuronal cells

Sung Hoon Kim1†, Ji Hyun Kim1, Jun Young Park1*, Ahreum Baek1,2, Eun Jee Park4, Bae-geun Nam3, Sang Woo Jun4, Sung-Rae Cho3,5

Yonsei University Wonju Colleage of Medicine, Department of Rehabilitation Medicine1, Yonsei University Wonju Colleage of Medicine, Department of Global Medical Science2, Yonsei University College of Medicine, Department and Research Institute of Rehabilitation Medicine3, The Graduate School Yonsei University Wonju, Department of Rehabilitation Medicine4, Yonsei University, Brain Korea 21 PLUS Project for Medical Science5, Yonsei University College of Medicine, Yonsei Stem Cell Center, Avison Biomedical Research Center6

Introduction Repetitive transcranial magnetic stimulation (rTMS) can be used to various neurological disorders. Although neurobiological mechanism of rTMS is not well known. Therefore, in this study examined the global gene expression patterns depending on different frequencies of repetitive magnetic stimulation (rMS) in neuronal cells to generate a comprehensive view of the biological mechanisms. Materials and Methods The mouse neuroblastoma cells, Neuro-2a cells, were randomly divided into three groups – the sham group, the low- and high-frequency group– and were stimulated over three days. The low- and high-frequency groups of rMS were characterized by transcriptome array. Differentially expressed genes were analyzed using the Database of Annotation Visualization and Integrated Discovery program, which yielded a Kyoto Encyclopedia of Genes and Genomes pathway. Results Among several pathways, long-term potentiation (LTP) pathway is an enriched significant pathway in high-frequency compared to low-frequency of rMS. The genes were involved in LTP pathway was validated by quantitative real-time polymerase chain reaction and immunoblotting. The expression of glutamate ionotropic receptor N-Methyl D-Aspartate 1, calmodulin-dependent protein kinase II (CaMKII)δ, and CaMKIIα was increased, and CaMKIIγ was decreased in high-frequency of rMS. These genes can activate the calcium (Ca2+)- CaMKII-cAMP-response element binding protein (CREB) pathway. Furthermore, high-frequency of rMS induced phosphorylation of CREB, brain-derived neurotrophic factor transcription via activation of Ca2+-CaMKII-CREB pathway. Conclusion These findings may help clarify further therapeutic mechanisms of rTMS.

Key words Repetitive magnetic stimulation, Low-frequency, High-frequency, Ca2+-CaMKIICREB pathway, brain-derived neurotrophic factor

P38

Comparison of MMSE and MoCA as a Tool for Assessing Intellectual Disability

JaeHoon Sim1*, ShinYoung Kwon1, KyeHee Cho1, JongMoon Kim1, MinYoung Kim1†

CHA Bundang Medical Center, CHA University, Department of Rehabilitation Medicine1

Introduction Many patients with brain lesion experience cognitive impairments. The degree of cognitive decline is an important factor in determining quality of life of survivors. Therefore, accurate assessment is important for effective intervention of cognitive dysfunction. The Wechsler Adult Intelligence Scale, fourth edition (WAIS-IV) Full Scale Intelligence Quotient (FSIQ) enables detailed cognitive assessments; however due to time-consuming and poor cost-effectiveness, the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) are more widely used. The MoCA is known to be more sensitive in detecting mild cognitive impairment than MMSE. Visuospatial/execution domains of MoCA provide an advantage over the MMSE. In this study, we aim to compare the MMSE and MoCA with other measures of cognitive function including WAIS-IV. Materials and Methods This retrospective review was based on chart review of patients hospitalized for brain injury between February 2017 and February 2018. Inclusion criteria were as follows: 1) confirmed brain lesion on MRI, 2) subacute stage within 6 months after the onset. However, patients with 1) a history of previous brain injury, 2) neurodegenerative diseases such as Alzheimer’s dementia and Parkinson’s disease, 3) psychiatric comorbidities were excluded. Baseline cognitive function was assessed with following parameters: MMSE, MoCA, sub-indices of WAIS-IV; Verbal Comprehension Index, Perceptual Reasoning Index, Working Memory Index, and Processing Speed Index, and FSIQ, Aphasia Quotient (AQ), Memory Quotient (MQ), Motor-Free Visual Perception Test-3 (MVPT-3), and Loewenstein Occupational Therapy Cognitive Assessment (LOTCA). Assessments of cognitive function, language, and visual perception were performed within one week after admission by psychotherapist, language therapist, and occupational therapist, respectively. Spearman’s correlation test was used on ordinal scale data. For statistical analysis, SPSS (IBM, version 21) was used. Results A total of 36 patients with brain lesion (right side 19, left side 13, and other lesions 4) were enrolled for the study as shown in Table 1. The MoCA showed higher correlation in all subtests of the IQ than MMSE. Interestingly, the visuospatial score of the MoCA showed significant correlation with PRI values in left brain injured patients (Figure, r=0.824, p=0.001). Both MMSE and MoCA scores correlated significantly with the MVPT-3 while AQ and LOTCA did not show any correlation with either measure.(Table 2 and 3)

Conclusion The MoCA was associated with IQ subscores more than the MMSE in assessing the intellectual disability of patients with brain lesion. In addition, the advantage of MoCA over the MMSE in assessing the visuospatial function can be supportive in identifying defective domain of intelligence. Further study with larger sample size will be helpful to identify specific dysfunction of cognitive subdomains in patients with brain lesion. Table 1. Demographics and cognitive assessments of patients by lesion location

Table 2,3. Correlation of MoCA/MMSE and other cognitive assessments

Fig. Correlation between the MoCA visuospatial subscore and the PRI of WAIS-IV in patient with left

hemisphere brain lesion

P39

Effect of Task Specific Lower Extremity Training in Cognitive Function with Stroke Patients

Lee Hi Chan1*, Ji Hyun Kim1, Sang Yeol Yong1, Young Hee Lee1, Jung Mee Park1, Sung Hoon Kim1†, Sae Hoon Chung1

Wonju Severance Christian Hospital, Department of Rehabilitation Medicine1

Objective The aim of this study was to elucidate effect of task specific lower extremity training in cognitive and gait function with stroke patients. Methods Thirty-eight patients were randomly assigned to a task specific lower extremity training group and a control group. The task specific lower extremity training group was trained a task specific lower extremity therapy and a conventional physical therapy. The control group was trained two sessions of conventional physical therapy. Each group was trained 5 days a week for 3 weeks. After that, both groups were trained conventional physical therapy 5 days a week for 2 weeks, equally. The primary outcome was assessment with the Mini-Mental State Examination, Global Deterioration Scale, visual and auditory digit span test, forward and backward. The secondary outcome was evaluated by berg balance scale, 10 meters walking test, 6 minutes Walking Test, Time UP and GO Test, Korean-Modified Barthel Index. The outcome measures were assessed before and after 3 weeks of training and 5 weeks follow up. Results After training, the task specific lower extremity training group showed significant improvement in global deterioration scale compared with the control group after 3 and 3 weeks. There was significant improvement in backward visual span test at only the task specific lower extremity training group after 3 and 5 weeks. The task specific lower extremity training group was statistically significant improvement in berg balance scale and 6 minutes walking test compared with the control group. Conclusion Task specific lower extremity training could be useful strategy for improving cognitive and gait function in stroke patients.

P40

The relationship between the time of line bisection test and cognitive function

Jong Moon Kim1*†, Shinyoung Kwon1, Min Young Kim1

CHA Bundang Medical Center, CHA University Rehabilitation and Regeneration Research Center, CHA University, Department of Rehabilitation Medicine1

Introduction Hemispatial neglect is defined by the inability of a person to process and perceive stimuli on one side of the body or environment. It is closely related to the deterioration of cognitive function. The line bisection test (LBT) is most commonly performed to confirm hemispatial neglect and the results within 5 minutes are considered. Although the time to complete the test is closely related to the cognitive function, there is no study considering time concept. In this study, we measured the time of LBT and tried to confirm the relationship with cognitive function through Mini-Mental State Examination (MMSE). Materials and Methods Thirty patients who were admitted to the rehabilitation department with brain injury were enrolled from September 2017 to February 2018. The patients were included 1) ischemic/hemorrhagic stroke and brain tumor, 2) subacute stroke (onset < 6 months), and 3) more than 1 step verbal command obey. LBT and MMSE were performed at the time of admission, and one month later. The time to complete the LBT was also measured. The correlation between LBT time change and MMSE score change was confirmed by Pearson correlation coefficient. Results The demographic factor of the patient was as shown in Table 1. Comparing LBT time change and the MMSE subscale score change, the total score (r = 0.374, p = 0.042) and the recall domain (r = 0.374, p = 0.042) showed a positive correlation (Table 2). Conclusion LBT and MMSE are one of the most commonly used testing tools for patients with brain injury. A significant correlation between LBT time change and the total score and the recall subscale score change in MMSE is considered to be related to attention. Measuring time when performing LBT is simple and can be used as a tool to predict the prognosis of cognitive function related to attention. Further study with larger sample size and follow up study is necessary.

Table 1. Baseline and clinical characteristics of the patients with brain injury

Table 2. The relationship between line bisection test time change and MMSE subscale score change in

patients with brain injury

P41

The effect of hypokalemia on functional outcome in subacute stroke patients

Young seok Kim1*, Hosung Yi2, Jinyoung Park1, Yoon ghil Park1†

Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine1, Department of Physical and Rehabilitation Medicine, Daegue Hospital, Korea Worker's Compentation & Welfare Service2

Background A stroke is defined as abrupt onset of a neurologic deficit attributable to a focal vascular cause. The release of osmotically active substances like arachidonic acid, electrolytes, lactic acid from the brain tissue causes cerebral edema followed by vascular injury and electrolyte imbalance. There were few studies about the relationship between the potassium level and the functional outcome after stroke. This study presents the effect of hypokalemia on functional outcome in subacute stroke. Methods Patients This is a retrospective study including consecutive hemiplegic patients after acute stroke who admitted from March 2014 to March 2017. By the serum potassium level examined within a week from admission, patients were classified into two groups: hypokalemic group with serum potassium <3.5 mmol/L and normal group with potassium 3.5 to 5.5mmol/L. Patients with serum potassium level > 5.5mmol/L, quadriplegic patients and past stroke history were excluded. Baseline characteristics Baseline characteristics of patients were a: age, sex, duration of hospitalization and initial functional assessment including muscle strength, functional ambulation category (FAC), functional independence measure (FIM), national institute of health stroke scale (NIHSS), mini mental status examination (MMSE), and glasgow coma scale (GCS). Past medical history was also reviewed which could affect the serum electrolyte level. Functional Outcome The primary outcome was measured: the change in strength assessed by manual muscle testing of bilateral upper and lower extremities, ambulatory function by FAC and FIM (subcategory of locomotion), and cognition by MMSE. Statistical analysis Student’s t-test was performed to examine the differences between two groups. Differences between categorical variables were calculated using Pearson correlation analysis. SPSS (version 24.0; SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. Results Total 99 patients were enrolled, of which 47 (47.5%) were hypokalemia group and 52 (52.5%) were normal group. There are no significant differences in baseline characteristics between two groups including past medical history: hypertension (p=0.39), arrhythmia (p=0.84), renal impairment (p=0.80) and more than two comorbidities (p=0.99). Only the hospitalization period showed a significant difference (46.8 days in hypokalemia group and 38.8 in normal group, p=0.02). The potassium level was significantly correlated with motor improvement of upper extremities (r= 0.20 p= 0.05),

lower extremities(r= 0.24, p= 0.019) and four extremities(r= 0.23, p= 0.02). FIM locomotion (r= 0.23, p= 0.02) and FAC(r= 0.24, p= 0.02) also showed significant associations. Conclusion Hypokalemia could be associated with poor functional outcomes after subacute stroke. Further data accumulation is needed to determine if potassium is a risk factor for poor functional outcome after stroke and to determine to which level should be controlled. Table 1.Pearson correleation coefficient (r) of functional improvement in subacute stroke patients with

serum hypokalemia level

P42

The effect of post-stroke delirium on functional outcomes

Yoo Young-Hwan1*, Lim Ju-Young1, Jung Han-Young1, Joa Kyung-Lim1†

Inha University School of Medicine, Department of Physical & Rehabilitation Medicine1

Objective Delirium is an acute attention and cognitive dysfunction. Although, the incidence of post-stroke delirium varies widely from 13% to 48%, few studies was reported about the effect of delirium on functional outcomes after stroke. The aim of this study is to evaluate the effect of delirium on functional outcomes such as motor, balance, cognition and activities of daily living (ADL). Subjective and method Data were collected retrospectively from the medical records of patients who were diagnosed with ischemic and hemorrhagic stroke and hospitalized from March 2015 to February 2017 at the OO University Hospital. A total of 231 new onset stroke patients have been enrolled. Among the 231 patients, 45 patients were diagnosed with delirium. Patients who showed symptoms such as altered fluctuating consciousness and disorientation were referred to psychiatrist. DSM-V criteria was used to define delirium. Baseline demographic and hospital data including age, sex, site of brain lesion, and length of stay (LOS) were analyzed. Information regarding functional status was based on the Korean version of the Modified Barthel Index (K-MBI), the Korean version of Berg Balance Scale (K-BBS), the Korean version of Mini-Mental State Examination (K-MMSE), and the National Institutes of Health Stroke Scale (NIHSS) for initial and discharge. Outcomes of rehabilitation were measured by gain and efficiency. Gain is the difference between admission and discharge ratings. Efficiency, which refers to the average change in ratings per day, is calculated for each patient by subtracting admission from discharge ratings and then dividing by the length of day measured in days. Results Demographics and clinical characteristics are summarized in Table 1. Mean age of the delirium group was 67.7 ± 12.1 years, and 48.9% were male. The LOS was significantly longer in the delirium group compared to non-delirium group (p<0.05). The delirium group showed significantly dominant in right brain hemisphere (p<0.05) and more frequent hemorrhagic stroke than non-delirium group (p<0.05). K-BBS, K-MBI efficiency was significantly different in the delirium group and non-delirium group, showing lower K-MBI and K-BBS efficiency in delirium group (Table 2). Improvements of K-BBS and K-MBI were significantly higher in non-delirium group (p=0.00) (Fig. 1). Conclusions Post stroke delirium can adversely effect on functional outcomes especially in balance, motor, and ADL functions. Early awareness, recognition of delirium, and intervention in stroke patients could improve the functional outcomes especially in motor, balance, and ADL functions.

Table 1. Demographics and clinical characteristics

Table 2. The gain and efficiency of functional outcomes

Fig. 1 Improvement of K-BBS, K-MBI, NIHSS, and K-MMSE between delirium group and control (non-delirium)

group

P43

CPAP Treatment in Subacute Stroke Patients with Obstructive Sleep Apnea : A pilot study

Ho wook Kim1*, Yeong wook Kim1†, Sungju Jee1†, Min Kyun Sohn1†

Chungnam National University, School of Medicine, Department of Rehabilitation Medicine1

Objective Obstructive sleep apnea (OSA) in stroke patients is associated with worsening functional and cognitive status during inpatient rehabilitation. The aim of this study was to evaluate the effectiveness of CPAP treatment in stroke patients during inpatient rehabilitation period using a neuropsychological and functional assessments. Materials and Methods We performed a randomized controlled trial in subacute stroke patients(ischemia and hemorrhage) admitted to department of rehabilitation medicine after November 2017. To dignose OSA, we performed sleep examination by portable polysomnography (Stardust II™, Respironics Inc. USA). OSA was diagnosed when Apnea-Hypopnea index (AHI) is higher than 20/h. Patients were randomly divided to 2 groups as follow : control group(rehabilitation treatment as usual) or CPAP group (CPAP treatment). Baseline clinical data were evaluated at the time of admission to department of rehabilitation medicine. We assessed stroke severity, neurologic function, cognitive impairment, and quality of life. Quality of sleep was assessed by using Epworth Sleepiness Scale (ESS). Tests were performed at baseline and after the two-week of intervention period. Results Ten patients participated in this study, 4 patients were excluded from the study. Because they were not OSA patients. Six OSA patients were included. The two groups(Control vs CPAP group) seems to be no differences in improvement on National Institute of Health Stroke Scale (NIHSS), modified Rankin scale (mRS), functional ambulation categories (FAC), Korean version modified Barthel Index (K-MBI), Berg balance scale(BBS) and EuroQol 5 dimensions questionnaire (EQ-5D). The CPAP group showed improvement in the cognitive functioning and Epworth Sleepiness Scale (ESS)(Table1). In polysomnographic study, the CPAP group showed improvement in obstructive apneas index compared with the control group(Table 2). Conclusion CPAP treatment seems to be improves cognitive status and quality of sleep in stroke patients with OSA. Additional patient enrollment is required to determine the effects of CPAP treatment on cognitive and functional status in subacute stroke patients.

Table 1. Clinical characteristics of patients with and without CPAP

Table 2. Polysomnographic data of patients with and without CPAP

P44

Effect of Inter-departmental Stroke Meeting in Comprehensive Cerebrovascular Center : A pilot study

Dongmin Hwang1*, Yeongwook Kim1†, Sungju Jee1†, Min Kyun Sohn1, Hyeon Jo Kwon2

School of Medicine, Chungnam National University, Department of Rehabilitation Medicine1, Chungnam National University Hospital, Daejeon-Chungnam Regional Cardiocerebrovascular Center2

Introduction Stroke is the third leading cause of death and a primary cause of long-term disability in the korea(2012), with >60% of surviving stroke patients burdened with residual neurologic deficits. Effective rehabilitation after stroke can minimize functional disability, enhance recovery toward independence, and optimize community participation. Moreover, early rehabilitation interventions in the stroke patients improve their muscle strength and physical functioning, as well as decrease the duration of pre rehabilitation period. So, we evaluated the stroke meeting’s effectiveness for hemorrhagic stroke patients management by comparing intervention before and after its initiation. Method Inter-departmental stroke meeting has been held from May 2014 once a week. In the meeting all the physicians such as neurologist, neurosurgeon, physiatrist participated in the review of acute stroke treatment, decision for secondary prevention and plan for rehabilitation. Medical records of 150 acute hemorrhagic stroke patients who had admitted at department of neurosurgery through emergency room in medical center that equipped for emergency care from September 2013 to August 2015 were reviewed retrospectively. Patients were classified into 3 groups : those admitted between September 2013 and April 2014 (group 1), those admitted between May 2014 and December 2014 (group 2), and those admitted between January 2015 and August 2015 (group 3). The patients of group 1 did not have Inter-departmental stroke meeting but the patients of group 2 and 3 did have. The independent T-test was used to analysis the mean of variables between groups. Results The number of group 1, 2, and 3 were 47, 52, and 51 respectively. (Table 1) The number of patients who were transferred to department of rehabilitation medicine was 65 out of 150. In comparison of transfer rate depending on whether or not the stroke meeting, there were not statistically different. Length of stay before transfer to department of rehabilitation medicine was reduced to 26 days from 33 days after performing the stroke meeting. Length of stay after transfer to department of rehabilitation medicine was reduced to 39 days from 58 days after performing the stroke meeting. Conclusions This study found that Inter-departmental stroke meeting was significantly correlated with improvement of length of stay. These results suggests that the therapeutic flow of

hemorrhagic stroke patients was more efficient due to the stroke meeting. Thus, stroke meeting is also very important intervention to hemorrhagic stroke patients. Table 1

P45

Effects of neuromodulation and exercise on recovery of motor function in ischemic stroke rat model

JuanXiu Cui1*, Yeong Wook Kim1, Guk Seong Kim2, Min Kyun Sohn1, SungJu JEE1†

Chungnam National University, Department of Rehabilitation Medicine, School of Medicine1, Chungnam National University College of Medicine, Department of Physiology2

Background and purpose Neuromodulation therapies have been used as an adjunctive treatment for promoting recovery of motor function in stroke patients. This study was designed to explore the therapeutic effect of repetitive transcranial magnetic stimulation (rTMS) and the exercise on neuroplasticity and recovery of motor function in a rat model of permanent middle cerebral artery occlusion (MCAO). Methods The forty rats were randomly divided as follows; the sham group (sham operation, n=10), and the middle cerebral artery occlusion group (operation, n=30). The middle cerebral artery occlusion group was randomly divided as the control group (No intervention, n=10), the rTMS group (rTMS only, n=10) and the combination group (rTMS combine with exercise, n=10). The high frequency rTMS (10 Hz) on ipsilesional forepaw motor cortex and exercise training by rotarod task were performed during 2 weeks. The rotarod test and garcia test were conducted at pre-operation, 3 days, 7 days, 10 days, and 15 days after MCAO operation. The motor evoked potential of ipsilesional forefoot was also measured at pre-operation, 3 days, and 17days after MCAO operation. The infarction area was measured with triphenyltetrazolium chloride staining at 17 days after MCAO operation. Results The rTMS group showed significantly better results in rotarod test, Garcia score and MEP amplitudes compared to the control group. However, the combination group showed more functional recovery than the rTMS group between 3 days and 7 days. There was no significant different in infarction area between 2 groups. Conclusions The rTMS combined with exercise therapy can be used as a treatment for recovery of motor function and neuroplasticity in stroke patients. Keyword rTMS ; exercise; neuroplasticity; motor function recovery; MCAO

P46

Effects of Newly Developed Trunk Stabilization Training Robot in patients with Chronic Stroke

Ji Hong Min1*, Hyun Yong Seong2, Sung Hwa Ko1, So Jung Kim1, Myoung-Hwan Ko3†, Yong-Il Shin1,2†

Pusan National University Yangsan Hospital, Department of Rehabilitation Medicine1, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology2, Chonbuk National University Hospital, Department of Rehabilitation Medicine3

Objective The objective of our study was to prove the therapeutic effects of used a newly developed trunk stabilization training robot (3DBT-33) on patients with chronic stroke. Method Thirty eight patients with chronic stroke were randomly assigned to an experimental or a control group. Both groups participated in conventional physical therapy for 30 mins a day, 5 days a week for 4 weeks. The robot group (n=19) received 30-min of trunk stability robot training in addition to conventional physical therapy. The control group (n=19) received the same amount of conventional physical therapy as the robot group. All participants were assessed by: : The Functional Ambulation Categories (FAC), Timed Up and Go test (TUG), the Berg Balance Scale (BBS), the Korean Modified Barthel Index (K-MBI) and the Fugl-Meyer Assessment of lower extremity (FMA-LE, the lower extremity part ranging from 0 to 36) before the intervention began (week 0) and after the intervention (week 4), as well as 4 weeks later after the intervention (week 8). Results In both groups, there were statistically significant improvements in all parameters (FMA-LE, K-MBI, FAC, BBS and TUG) at follow-up assessment after 4 weeks of intervention (p<0.05). When the two group’s training effects were compared, there were statistically significant differences in FMA-LE, K-MBI and BBS between the robot and control groups (p<0.05). There was no significant difference in FAC (p=0.935) and TUG (p=0.442). Conclusion The findings in the present study showed that trunk stabilization rehabilitation training using a newly designed rehabilitation robot in patients with chronic stroke was effective to improve gait and the ability to perform ADL, where it was even more effective than conventional therapy in improving the ability to perform ADL.

Results before and after intervention and significance between groups

P47

Effect of Injection Laryngoplasty on laryngeal dysfunction patients with ongoing cancer treatment

Min-Gu Kang1*, Han Gil Seo1, Seong Keun Kwon2, Eun-Jae Chung2, Seo Jung Yun1, Hyun Haeng Lee4, Bhumsuk Keam3, Tae Min Kim3, Byung-Mo Oh1†

Seoul National University Hospital, Department of Rehabilitation Medicine1, Seoul National University Hospital, Department of Otorhinolaryngology2, Seoul National University Hospital, Department of Internal Medicine3, Konkuk University Hospital, Department of Rehabilitation Medicine4

Background/Objective Vocal fold paralysis may occur during cancer diagnosis and treatment. It can be caused by nerve compression of cancers, or direct nerve injuries during tumor resections. Insufficient glottal closure may lead to swallowing dysfunction such as aspiration. The aim of this study is to investigate the effect of injection laryngoplasty for dysphagia in laryngeal dysfunction patients with ongoing cancer treatment. Methods A prospective study was conducted on the patients who 1) had been referred to the Department of Rehabilitation Medicine and Otorhinolaryngology of OOO Hospital for laryngeal dysfunction during cancer diagnosis and treatment, 2) had a unilateral vocal fold paralysis confirmed by laryngoscopy, and 3) aged 18 years old or older. Patients with cancer invasion into vocal folds were excluded. Videofluoroscopic Swallowing Study (VFSS) was conducted and analyzed by using the Clinical Dysphagia Scale (CDS), Video-fluoroscopic Dysphagia Scale (VDS) and Penetration Aspiration Scale (PAS). The patients underwent injection laryngoplasty using Radiesse™ (calcium hydroxyapatite). Three weeks after the injection, the patients were evaluated with a postoperative VFSS. Wilcoxon signed rank test was used to compare the variables between before and after injection laryngoplasty. Results A total of 15 patients were enrolled in this study. Table 1 shows the baseline characteristics of the participants. Lung cancer was the most common primary lesions and left vocal fold paralysis was more common than right paralysis. Table 2 shows the comparison of swallowing dysfunction before and after injection laryngoplasty. There was no statistical difference between before and after the injection. Conclusion Injection laryngoplasty may not be as effective as thought for improving swallowing dysfunction in these patients. However, in this study, swallowing dysfunction of the participants was mild before injection laryngoplasty. There is a possibility that this limitation masked the effect of injection laryngoplasty on dysphagia. Therefore, further studies which include patients with more severe swallowing dysfunction are needed to verify the effect of injection laryngoplasty.

Table 1. Clinical characteristics of the participants (n=15)

Table 2. Comparison of swallowing dysfunction before and after injection laryngoplasty

P48

A retrospective comparison study of training effects of Locomat and Walkbot in acquired brain injury

Hoo Young Lee1,3*, Jung-Hyun Park4, Jin Young Lee1,2, Tae-Woo Kim1,2†

National Traffic Injury Rehabilitation Hospital, Department of Rehabilitation Medicine1, The Catholic University of Korea Seoul St. Mary`s Hospital , Department of Rehabilitation Medicine2, Yonsei University College of Medicine, Department of Rehabilitation Medicine3, Gangnam Severance Hospital, Department of Rehabilitation Medicine4 Objective Two robotic exoskeletons, Lokomat and Walkbot are designed to provide active-assistive gait training by guidance and actuation of the leg movement. Lokomat has two actuated joints for hip and knee flexion, whereas Walkbot system is modulated by three actuated joints for hip, knee and ankle joints, bilaterally. The aim of this study is to investigate whether there are comparative effects on the motor recovery, balance and gait between Lokomat and Walkbot. Methods The clinical data warehouse was used for a retrospective comparative analysis. We reviewed the electronic medical records and analyzed Manual Muscle Testing (MMT), Fugl-Meyer Assessment (FMA) of lower extremity, Postural Assessment Scale for Stroke Patients (PASS), Berg Balance Scale (BBS), 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), Timed Up and Go test (TUG), Functional Ambulatory Category (FAC), Fuctional Gait Assessment (FGA), and the Korean Version of Modified Barthel Index (K-MBI)) of 85 patients with acquired brain injury who received robot-assisted gait training (RAGT) on the Lokomat (Hocoma AG, Volketswil, Switzerland) or Walkbot (P&S Mechanics, Seoul, Korea) for the period of about 2 years. Moreover, subjects were stratified using the FAC score into dependent ambulatory (FAC 0~2) and independent ambulator group (FAC 3, 4) for futher analysis. Results Onset age, sex, paralysis type, etiology, cognitive function, lag time to the intervention, baseline function were similar across groups. 44 and 41 patients received Lokomat and Walkbot assisted gait training, respectively, for 30 minutes, once a day, 2 to 3 times a week, for a total of 8 to 36 sessions. In total 85 subjects, both interventions showed beneficial effects in MMT on lower extremity, K-MBI scores on stair climbing, walking, transfer, and the total score, scores on BBS, PASS, FGA, and FAC in each group. Among them, only PASS showed significantly more beneficial effects in Walkbot group than Lokomat group (p<0.05). In the dependent ambulatory group, both Lokomat and Walkbot significantly improved MMT, MBI, PASS, BBS, FAC, FGA, and 6MWT (p<0.05). Walkbot group showed significantly more increase on PASS score than the Lokomat group (p<0.05). As to the independent ambulatory group, BBS, 10MWT, and total K-MBI scores showed significant improvement in both intervention groups (p<0.05). However, no comparative beneficial effectiveness was demonstrated between the exoskeletons.

Conclusion In this study, both Lokomat and Walkbot have beneficial effects in the balance and gait recovery in patients with acquired brain injury. Our investigation demonstrate that, of two robotic exoskeletons, there is no superior locomotor training intervention for motor recovery, balance and gait, but for PASS. Elucidation of these even therapeutic benefits in the robotic exoskeletons provides new insights into the robot-assisted locomotor training.

P49

Clinical characteritics related radionuclitde salivagram in chronic brain injuried patients

Ga Yang Shim1*, Ju Sun Oh1†, Seung Hee Han1, Jae Ho Oh1, Gyeng Yeol Choi1

Seoul Medical Center, Department of Rehabilitation Medicine1

Objective Pneumonia is most common complication and is related with mortality in chronic brain injuried patients. Saliva aspiration is common finding in chronic brain injuried patients with pneumonia. So we investigated the correlation between clinical characteristics and radinuclitide salivagram in chronic brain injuried patients. Subjective and Method We investigated retrospective medical record finding of patients with dysphagia in chronic brain injuried from January 2016 to March 2018. Motor-neuron disease, combined cord injury, non brain tumor and Alzheimer dementia patients were excluded. Then 31 patients had examination of radionuclitide salivagram and VFSS. We checked clinical character such as age, duration of disease, MMSE-K, K-MBI, Tracheostomy state, feeding method, brain lesion, VFSS PAS and VFSS Dysphagia scoring. Group comparison according to salivagram findings was performed using t-test, Pearson chi-square test and mutiple logistic regression analysis with forward stepwise. Results In 31 chronic brain injuries patients 23 patients showed positive finding in radionuclitide salivagram. Mean age was 65.3±14.42. 8 patients showed negative finidngs in radionuclitide salivagram and mean age was 60.37±22.41. Most cause of brain injuried was stroke in both positive and negitive finding in salivagram. In comparison findings between positive and negitive salivagram PAS, VFSS Dysphagia scoring, tracheostomy state and tube feeding were correlated with positive radionuclitide salivagram. Age and disesa duration at salivagram were not correlated with positive salivagram. And Tracheostomy state, PAS factor were significantly associated with postive salivagram by multiple logistic regression with forward stepwise. Conclusion In chronic brain injuried patients high PAS, VFSS Dysphagia scoring, tracheotomy state, non-oral feeding state were correlated with positive radionuclitide salivagram. Saliva aspiration is related with aspiration pnemonia so it is poor functional factor in chronic brain injuried. Age and disease duration are not related with positive radionuclitde salivagram. So if we consider that swallowing training or tracheostomy training in chronic brain injuried patients we evalated saliva aspiration risk and associated factors.

Table1. Characteristics and comparison of brain injured patients with and without on salivagram findings

Table2. Correlation factor between clinical characteristics and positive salivagram finding

Table3. Multiple logistic regression analysis with stepwise method of clinical characteristics related positive

salivagram finding

P50

Effect of discontinuing physical therapy on the change of spasticity in children with cerebral palsy

Heewon Lee, MD.1*, Bo young Hong , MD., Ph.D.1†, Joon Sung Kim, M.D., Ph.D.1, Seong Hoon Lim, M.D., Ph.D. 1, Bo Mi Sul M.D.1

St.Vincent Mary’s Hospital, Department of Rehabilitation Medicine1

Background and Objectives The importance of physical therapy in cerebral palsy (CP) patients to alleviate spasticity and prevent contracture is widely accepted. However there have been no studies suggesting that spasticity could be aggravated when rehabilitation program was discontinued. The aim of this study was to investigate the effect of physical therapy interventions on the spasticity of CP patients. Previous studies of CP had difficulty in discontinuing treatment, but in this study, there was a long official holiday period, which could be proceeded without ethical problems. Methods This study was a restrospective study, and thirty five CP patients were enrolled who had participated in our rehabilitation programs. Outcome measures were estimated according to the range of motion (ROM) of ankle joint and Modified Tardieu Scale (MTS). The angle of full range of motion at very slow speed was designated R2, and the angle of muscle reaction during a quick stretch as fast as possible was designated R1. Ankle ROM, R1 and R2 were measured in both knee flexion and knee extension positions. Pre and post assessment was performed before and after ten-day holiday while interrupting physical therapy. Statistical analysis was applied linear mixed model to analyze the degree of spasticity changes. Results Patient characteristics are presented in Table I. The mean age was 5.6 years (1–11 years). Of the 35 patients, all patients were corresponded to the spastic type of CP except one of the dyskinetic type of CP, and were classified between Gross Motor Function Classification System (GMFCS) levels I through V. The results showed that ankle ROM in the Knee flexion and the knee extension significantly decreased after holiday compared to before holiday [Fig 1]. In addition, in the analysis according to the GMFCS level, both R1 and R2 were significantly decreased in the Knee flexion and the knee extension after the holiday [Fig 2]. The results indicate that the interruption of physical therapy could increase the ankle joint spasticity.

Conclusion In the present study, we suggest that regular physical therapy of the children with CP is required to improve the spasticity control and maintain the range of motion. In previous studies there was a lack of evidence of adverse effects in discontinuing physical rehabilitation therapy. This study could be useful in setting up appropriate rehabilitation strategies for CP children by providing knowledge of the effects of treatment interruption on spasticity. Table 1. Patients characteristics

fig 1. The changes of Ankle ROM after holiday compared to before holiday

fig 2. The changes of R1 and R2 after holiday compared to before holiday according to the GMFCS level,

P51

Neurodevelopmental Outcomes in Very Low Birth Weight (VLBW) Infants at Corrected Age of 18 Months

Il Gyu Lim1*, Dong-Ki Min2, Han seong Choe3, So Young Lee1†

Keimyung University School of Medicine, Department of Physical medicine and Rehabilitation Medicine 1, Daegu Health College, Department of Physical Therapy2, Catholic University, Department of Physical Therapy3 Introduction The emergence of highly specialized care units in neonatal intensive cares has improved the survival of very low birth weight (VLBW) infants, however, improved survival might be associated with increased disability among survivors. Several reports are available regarding their adverse long term neurodevelopmental outcomes and associated risk factors. The purpose of this study was to investigate the neurodevelopmental outcome and associated risk factor of VLBWI at 18 months (corrected age). Methods and Materials We performed retrospective study in which we investigated neurodevelopmental outcome in 49 VLBWI who had been followed up for more than 18 months in rehabilitation department from January 2016 to December 2017. Neurodevelopmental outcome including cognition, motor, and language development were assessed at 18 months corrected age using the Bayley II scale and Sequenced Language Scale for Infants (SELSI). Results Out of 49 patients followed in the clinic, 25 patients (51.0%) were determined to be developmental delay on mental developmental index (MDI score <85). And 8 patients patients (16.3%) were determined to be developmental delay on Psychomotor developmental index (PDI score <85). Twenty three patients (46.9%) were determined to be receptive language delay, and 25 patients (51.0%) exhibited expressive language delay. Maternal characteristics including age and comorbidity (hypertension, diabetes mellitus) were not significantly associated with MDI score, PDI score, receptive language quotient and expressive language quotient. Factors were not associated with neurodevelopmental delay included intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, gestational age and birth weight. On the other hand, the duration (days) of invasive ventilator use was significantly associated with a decreased PDI score (Pearson correlation coefficient, -0.349, P = 0.014). Conclusion To increase the survival rate of VLBW infants and effectiveness of early intervention, the risk factors for neurodevelopmental delay should be avoided. Routine neurodevelopmental screening for neonates and infants for early detection of neurodevelopmental delays and appropriate rehabilitation intervention is highly recommended for VLBWI who had invasive ventilator use.

P52

Early Assessment of Visual Impairment in Preterm Infants using the PreViAs Questionnaire.

Mee Gang Kim1*, Jungjae Lee1, Donggyun Sohn1, Soyeon Jun1, Kyung Eun Nam1, Ah-Ra Cho1, Joo Hyun Park1†

Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Department of Rehabilitation Medicine1

Introduction Preterm birth is known as a risk factor for deficit of neurological and cognitive development. Among various neurobehavioral deficits in preterm infants, visual difficulties may not only be due to ophthalmologic diseases but also be caused by problems in higher cerebral structures. Early visual assessment in high-risk infant can be helpful to predict later visual and cognitive outcome as well as to measure existing deficits. There are several tools to assess visual function in children, but most of them are time-consuming and require an experienced evaluator. Materials & Methods The Preverbal Visual Assessment (PreViAs) questionnaire designed by V. Pueyo et. al, is a easy tool which is proven effective to assess visual cognitive abilities in healthy children or in children with high risk under 24 months of age, through primary caregivers' answers. The PreViAs questionnaire consists of 30 items, and each item is related to one or more of four domains of visual behaviors (Table. 1). The authors have set the normal references in full term infants, and validation was performed in infants with abnormal visual maturation. We preliminarily introduced this questionnaire to the patient and caregiver visiting our outpatient clinic to assess the visual behaviors in preterm infants. The caregivers of 90 patients have completed the questionnaire. Among them, 67 patients were under 24 months of age, and 34 patients were born at preterm. The ages of preterm infants were corrected according to their gestational age at birth, ranged from 0.10 to 17.99 months, and divided into 7 groups. The domains were scored as the sum of the items corresponding to each visual cognitive behavior. The mean scores of each domain were compared to the standard references at each age group. Results & Discussion The number of preterm infants in each corrected age group, and the mean scores of each visual domain are shown in Table 2. As the sample size was very small, we looked over general tendency in preterm infants compared to the references of each domain. The mean global scores in preterm infants were generally lower than the references, except for age 4 to 5.99 months, 6 to 8.99 months, and 12 to 14.99 months. The mean scores of visual-motor coordination were lower than the references in all age groups. The mean scores of visual processing in preterm infants at each age group were generally lower than the references, except for age 12 to 14.99 months. The mean scores of visual communication were generally lower than the references, except for age 4 to 5.99months, and 12 to 14.99 months. The mean scores of visual attention were lower in

age 0 to 1.99 months, 2 to 3.99 months, and 15 to 17.99 months than the references. (Figure 1) The PreViAs questionnaire can be a quick and easy tool to assess the visual cognitive abilities of each domain in preterm infants. Further studies are necessary to validate the usefulness of the questionnaire for this purpose. Table 1. The Preverbal Visual Assessment (PreViAs) questionnaire. Developed by V. Pueyo et. al,

Development of the Preverbal Visual Assessment (PreViAs) questionnaire, Early Human Development 90

(2014) 165–168. Abbreviations: VA, visual attention; VC, visual communication; VMC, visuomotor

coordination; VP; visual processing

Table 2. The number of preterm infants in each corrected age group, and the mean scores of each visual

domain.

Fig 1. The mean scores of each visual domain at each age group in preterm infants, compared to the normal

references. Blue; The mean scores of normal infants (from V. Pueyo et. al, Development of the Preverbal

Visual Assessment (PreViAs) questionnaire), Red; The mean scores of preterm infants.

P53

Relationship between Amplitude of Common Peroneal Motor Conduction and L5 Radiculopathy

Taejune Park1*, Ho Jun Lee1†, Bumsun Kwon1, Jin-woo Park1, Kiyeun Nam1, Jung Hwan Lee2, Hee Jae Kim1, Yong Jin Jo1

Dongguk University Ilsan Hospital, Department of Rehabilitation Medicine1, Dongguk Univeristy Gyeongju Hospital, Department of Rehabilitation Medicine2 Objective To investigate the incidence of reduction of compound muscle action potential (CMAP) amplitude of common peroneal nerve and associations between reduction of CMAP amplitude of common peroneal nerve and clinical factors or the severity of image measurement in L5 radiculopathy. Method We retrospectively reviewed findings of electro-diagnostic study (EDX) and magnetic resonance imaging (MRI) of patients who were diagnosed with unilateral L5 radiculopathy and lumbar herniation of intervertebral disc (HIVD). 35 patients were enrolled and we investigated demographic and clinical characteristics (age, gender, duration of illness, straight leg raising test, motor power of ankle dorsiflexior (ADF) and big toe extensor (BTE)). We investigated CMAP amplitude of both common peroneal nerves with ratio (affected side to healthy side) and findings of needle electromyography (EMG). We also investigated MRI at the level of the L4-5 intervertebral disc for the severity of disc herniation with qualitative measurements (Pfirrmann root compromise grade, HIVD description depending on Recommendations of the combined task forces (CTF) of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology) and quantitative measurements (cross sectional area (CSA) of spinal canal and dural sac). Statistical analyses were performed using SPSS-K version 24.0. Result Reduced amplitude of CMAP (ratio < 1.0) was found in 22 (63%) patients. Ratio under 0.7 was in 12 (34%) patients and ratio under 0.5 was in 7 (20%) patients. In patients with CMAP ratio under 0.7, motor power of BTE showed significant decrease (P-value=0.041) and other clinical characteristics and MRI measurement showed no significant difference. In patients with CMAP ratio under 0.5, there was significant difference only in onset duration (47.3±94.3 vs 8.0±10.7 (weeks), P-value =0.031) and no significant differences in other clinical characteristics and MRI measurements. Analyses of all patients showed significant negative correlation between CMAP ratio and onset duration (R=-0.363, P-value=0.032) and positive correlation between CMAP ratio and motor power of BTE (R=0.364, P-value=0.032). However, there were no significant correlations between CMAP ratio and MRI measurements.

Conclusion 63% patients with HIVD in L4-5 level and L5 radiculopathy had reduced CMAP amplitude of common peroneal nerve. Patients with significantly reduced CMAP amplitude had a tendency of weaknessof big toe extensor and chronic stage of disease. There were no significant relations between reduced amplitude of CMAP and the severity of MRI image. This study was preliminary study and further study with larger number of patients is necessary to investigate the clinical significance and diagnostic value of CMAP ratio of common peroneal nerve in L5 radiculopathy.

Pfirrmann root compromise grade

(A) Spinal canal CSA measurement, (B) Dural sac CSA measurement

P54

Clinical Implication of Serial Neurophysiologic Study in Diagnosis of CIPN

Youngsu Jung1*, Jaewoo Choi1, Kiyoung Kim1, Mi Ri Suh1, MinYoung Kim1, Sang Hee Im2†

Bundang CHA, Department of Rehabilitation Medicine1, Severance Hospital, Department of Rehabilitation Medicine2

Objective Taxane families are widely used in the management of patients with breast and ovarian cancers. Dose-limiting toxicity of taxanes is related to a distal sensory neuropathy, with symptoms of sensory loss and paresthesia in the extremities that can significantly impact quality of life in cancer survivors. However, the assessment of chemotherapy induced peripheral neuropathy (CIPN) is still based not on the objective findings of neurophysiologic study, but on clinical symptoms. Therefore, the aim of this retrospective study is to demonstrate neurophysiologic changes in symptomatic subjects early after and during chemotherapy and to suggest new criteria in diagnosing CIPN. Methods The medical charts of subjects with breast or ovarian cancers who visited university hospital between April 1, 2017 and January 1, 2018 were reviewed. Inclusion criteria were history of chemotherapy with taxane-containing regimen, sensory symptoms of glove and stocking distribution compatible with neuropathic pain (those with Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale ≥12), and those who had undergone nerve conduction study (NCS) twice during or after the chemotherapy. Subjects were excluded if they had predisposing condition for neuropathy, such as diabetes mellitus, thyroid disease, alcohol abuse history, and previous chemotherapy for other malignancies. Demographics and clinical features were acquired along with parameters of body mass index, body surface area, the regimen and the number of chemotherapy, LANSS Pain Scale, and the Sensory Nerve Action Potentials (SNAPs) recorded in the sural nerves. Results Data from 23 subjects were collected. Baseline characteristics are described in Table 1. All subjects scored over 12 in LANSS Pain Scale, subjectively having symptoms compatible with neuropathic pain. Follow-up NCS was performed after 2.2 months on average (Figure). Among the subjects who suffers from neuropathic pain after taxane-containing chemotherapy, only 10 out of 23 (43.5%) showed sural SNAP amplitude lower than 10uv in initial NCS. Additional five subjects developed sural SNAP amplitude lower than 10uv in the follow-up NCS (15 out of 23, 65.2%). Between the first and second NCS, 10 subjects showed more than 30% drop of sural SNAP amplitude (10 out of 23, 43.5%). The results are summarized in the Table 2. Conclusion Considering the evidence of axonal injury in the sural nerve, maximum of 65.2% patients was determined as CIPN. However, including the subjects with more than 30% drop of

sural SNAP amplitude, serial NCS results could support as much as 78.2%.Therefore, serial NCS studies during chemotherapy may be helpful in assessing the chemotherapy induced nerve damage and to attain the objective evidence of CIPN. Evidence of axonal injury in sural nerve with more than 30% drop of SNAP amplitude in follow-up NCS can be used as a sensitive marker of early detection for CIPN. Table 1. Baseline characteristics

Fig. Clinical and neurophysiologic features in two serial visits

Table 2. Sensitvity of Neurophysiologic Criteria in Diagnosis of COPN

P55

The clinical outcome of lumbosacral plexopathy according to the extent and etiology of the injury.

Won Jin Sung1*, Seong Hoon Lim1†, Joon Sung Kim1, Bo Young Hong1, Bo Mi Sul1, Jung Jae Lee1

St. Vincent’s Hospital, Korea., Department of Rehabilitation Medicine1

Introduction & Background The lumbosacral plexopathy is defined as a neurological disorder derived from lumbosacral plexus(composed of both the upper lumbar and lower lumbosacral plexuses). The causes of lumbosacral plexopathy vary widely, ranging from pelvic trauma or compressive causes(i.e.; hematoma) to neoplastic or vascular diseases. Although a Few studies have investigated the clinical outcome of lumbosacral plexopathy, the clinical findings and outcomes of lumbosacral plexopathy are not yet clear. This study investigated the clinical outcome of lumbosacral plexopathy in terms of the extent and etiology of the injury. Methods We designed a retrospective study. We reviewed the medical records of 23 lumbosacral plexopathy patients who presented between January 2011 and December 2017 to the Department of Rehabilitation Medicine of one university hospital in Korea. All of the patients were diagnosed with lumbosacral plexopathy after careful clinical and electrophysiologic evaluation. They were divided into different groups according to the etiology and extent of their injuries and the clinical outcomes of each group at one year after onset were investigated. Clinical outcomes were classified into the following four categories. “Full recovery” includes patients with complete recovery of their neurologic symptoms. “Able to walk” and “unable to walk” depend on the availability of independent walking, and finally “loss to follow-up” for those patients who we lost track of. The anatomic extent of the nerve injury of each patient was confirmed by thorough nerve conduction study and needle electromyography. Results We reviewed the histories and the results of electrodiagnostic studies of 23 patients (mean age 43.3±16.1; 13 males, 10 females)[Fig 1]. Right lumbosacral plexus was involved in 11 patients, left lumbosacral plexus in 8, and bilateral plexuses in 4. Among the 27 lumbosacral plexuses(due to 4 patients with bilateral lesions), upper lumbar plexus was involved in 6 cases, lower lumbosacral plexus in 12, and the whole lumbosacral plexus in 9. There were 13 cases which arose from traumatic event, and the rest were non-traumatic. When the clinical outcomes between the groups were compared, Non-traumatic cases showed higher rates of “full recovery” than traumatic cases[Fig 2-a]. Those with lesions in the upper lumbar plexus had a higher chances of “full recovery” than the others[Fig 2-b].

Conclusion Patients with non-traumatic lumbosacral plexopathy showed better outcomes than those with traumatic plexopathy. Furthermore, those with injuries limited to upper lumbar plexus showed better outcomes than those with injuries involving lower lumbosacral plexus or whole lumbosacral plexus. There results will be useful when planning treatment strategies and will deepen our understanding of prognosis of lumbosacral plexopathy.

Fig 1. Clinical characteristics of patients.

Fig 2-a Clinical outcome of lumbosacral plexopathy according to etiology(trauma vs non-trauma)

Fig 2-b Clinical outcome of lumbosacral plexopathy according to the injury extent.

P56

Optimal Recording Site of the Trapezius in the Preoperative Patient with Head and Neck Cancer

Ki Hoon Kim1*, Se Young Shin1, Dong Hwee Kim1†

Korea University Ansan Hospital, Department of Rehabilitation Medicine1

Objective To determine the optimal recording site of the trapezius muscles in motor nerve conduction study in the preoperative patients with head and neck cancer. Methods A total of 32 upper (UT) and middle (MT) trapezius muscles of 16 preoperative patient with head and neck cancer were recruited retrospectively. The spinal accessory nerves were stimulated on the posterior margin of the sternocleidomastoid muscle at the midway between mastoid process and suprasternal notch. For UT recording, the midpoint (point M) between the C7 spinous process and the acromion was determined. Active recording electrode was placed on the 4 cm (P4) and 2 cm (P2) proximal to point M, point M, and 2 cm (D2) and 4 cm (D4) distal to point M in sequence. For MT recordings, active recording electrodes were located on the following sites: midpoint between the root of scapular spine (Sc) and vertebral spinous process (SP) at the level; medial and lateral one third between the Sc and the SP. Results The mean age were 62.1±12.1 years. The distance between the C7 spinous process and the acromion was 20.7±1.0 cm. The compound muscle action potential (CMAP) amplitudes of the UT were 4.4±1.0, 7.3±1.3, 8.4±1.6, 5.4±1.3, and 3.2±1.2 mV with the recordings in the P4, P2, M, D2, and D4, respectively. The CMAP amplitudes of the MT were 3.9±1.5, 2.6±1.1, and 4.3±1.6 mV with recording in the midpoint between the root of scapular spine (Sc) and vertebral spinous process (SP) at the level, medial and lateral one third between the Sc and the SP, respectively. Conclusion The optimal recording site of the upper trapezius muscles in motor conduction study was the midpoint (M) between the C7 spinous process and the acromion.

P57

Relationship between Handgrip Strength and Cardiopulmonary Fitness in Myocardial Infaction

Seung-Hyun Boo1*, Geon Sang Lee1, Ji Woo Park1, Ji Hee Kim1†

Wonkwang University School of Medicine & Hospital, Department of Rehabilitation Medicine1 Purpose The purpose of this study was to investigate the relationship between hand grip strength and cardiopulmonary fitness in patients with myocardial infarction. We hypothesized that patients with low grip strength would present an unfavorable cardiopulmonary function. Methods This study was designed as a cross-sectional, case controlled study. A total of 67 participants who experienced myocardial infarction were recruited for 1 consecutive years from February 2017. The hand grip strength were measured by handheld dynamometer. The patients squeezed the dynamometer three times with both hands using maximum effort. The mean of three trials was recorded respectively. Dynapenia was diagnosed on the basis of dominant hand grip strength less than 26 kg for male and 20kg for female. Cardiopulmonary exercise test was performed using a treadmill and a 12-channel electrocardiogram according to modified Bruce protocol. During the entire test, exhalation gases were analyzed in real time using a respiratory gas analyzer. The test was terminated immediately when participants requested termination Results Of the 67 subjects, 60 were males and 7 were females and the mean age of the patients was 56 ± 9 years (Table 1). The mean dominant and non-dominant handgrip strength was 34.2±8.6 kg and 32.2±8.8 kg, respectively. Dynapenia was diagnosed in 14.9% (n=10) of the participants and cardiorespiratory fitness parameters including maximal oxygen consumption (VO2max), ventilatory threshold (VT), maximal O2pulse (O2pulsemax), minute ventilation (VEmax) and exercise time were significantly decreased in dynapenia group compared with non-dynapenia group (Table 2). Correlation analysis revealed that dominant handgrip strength was significantly related with VO2max (r=0.377, p<0.01), VT (r=0.450, p<0.01), O2pulsemax (r=0.485, p<0.01), VEmax (r=0.453, p<0.01), and exercise time (r=0.464, p<0.01) (Table 3). Conclusion Handgrip strength could potentially be used as a marker of cardiorespiratory functions. Therefore, proper management for the muscle strength should be considered to improve cardiopulmonary fitness in patients with myocardial infarction.

P58

Compliance of compression garment in 2-year follow up of lymphedema

Young Je Kim1*, Dong-KI Min2, Han seong Choe3, Soyoung Lee 1†

Keimyung University Dongsan Medical Center, Department of Rehabilitation Medicine1, Daegu Health College, Department of Physical Therapy2, Catholic University of Daegu, Department of Physical Therapy3

Introduction In patients with have lymphedema, the major goal of lymphedema treatment is to reduce edema volume in the long term and to maintain reduced state. Currently, Complex decongestive therapy is recognized as a standard lymphedema treatment. Among them, Self-management with compression garment is considered to be an important part of the patient's ability to control lymphedema and carry on with the treatment techniques implemented by professionals. The aim of this retrospective study was to investigate the compliance of compression garment in lymphedema patients who were admitted and educated self bandage. Materials and Methods This study included patients with arm lymphedema or leg lymphedema between January 1, 2013 and December 17, 2016. The inclusion criteria for this study were: 1) patients who were able to self-bandage at discharge and 2) patients who were followed up for more than one year after bandage education. A total of 75 patients were enrolled at one year follow-up and 58 patients for two year follow up in the study. The following clinical characteristics were obtained from retrospective chart review : Age, Sex, Location of lymphedema (arm or leg), Site of lymphedema (right or left) , Maximal circumference difference [MCD] (at admission/ at discharge / after 6 months / after 12 months / after 24 months) , types of compression garment (after 6 months / after 12 months / after 24 months) The limb circumferences were estimated using a measuring tape in five areas. Then, the maximal circumference differences (MCD) at the uppermost symptomatic areas were calculated. Results Our study comprised 75 patients with lymphedema. They consisted of 67 women and 8 men. Upper extremity lymphedema was present in 49 patients, and the remaining 26 patients had lower extremity lymphedema. The mean age of patients was 54 years. 89% of patients population was still performed their bandage or stocking as instructed six month after discharge, 91% one year and 88% two year after discharge. The bandage was most frequently used type of compression garment during all follow-up period (Figure 1). When upper and lower extremities were analyzed separately, bandage was most frequently applied methods for 2-year follow-up periods in the upper extremity. In contrast, stocking was more frequently applied than bandage since 12months after discharge in lower extremity.

Conclusion Patients with lymphedema who had the opportunity of being adherent to the compression garment during two years following their initial treatment were achieving their maximal volume reduction effect after discharge. It seems that comprehensive instruction is required after discharge and that periodic reviews are necessary for their compliance and adherence to compression garment for lymphedema.

Fig.1 Rate of applying to compression garment. (all patients, n=75)

Fig.2 Rate of applying to compression garment. (Upper extremity patients, n=49)

Fig.3 Rate of applying to compression garment. (Lower extremity patients, n=26)

P59

Development of the Wearable Knee Joint Sensor to remove Skin movement noise

kyung soo Jeon1*, Hee Seung Yang1†, Dong Young Ahn2, Woo Sung Seong2, Woo Sob Sim2, Min Jo2, Hyun Gi Moon3, Jang Hwan Kim4

Veterans Health Service Medical Center , Department of Rehabilitatin Medicine 1, Veterans Health Service Medical Center , Center of Prosthetics and Orthotics2, Hanyang University, Department of mechanical engineering3, Hanseo University, Department of Prosthetics and Orthotics4

Introduction The present paper deals with the development of a wearable knee joint angle measurement sensor. A new design sensor cover is also proposed which reduces noise signals related to virtual knee joint angle errors caused by change of coordinate location that is attributable to the motion of skin soft tissue during walk. Objective The study was designed to evaluate the efficacy of wearable knee joint sensor, compared with a three-dimensional infrared gait analysis system Methods The sensor module of this measurement system is based on inertial measurement uits(IMUs) sensor that can measure 2 DOF (Degree of Freedom) knee joint angles. The structure of the system allows sensors to be wearable on a thigh and a lower extremity respectively. The sensor thus developed was evaluated by Vicon®, a three-dimensional infrared gait analysis system. The experiment for the evaluation was conducted three times with the gait velocity of 3 km/h, 4 km/h and 6 km/h. Results The measurements obtained in a sagittal plane showed that the lowest root mean square error was 1.0˚±0.3 at gait velocity 3 km/h and the highest one was 3.4°±0.4 at gait velocity 6 km/h. It turned out that the proposed wearable knee joint angle measurement system had an error range that can ensure compatibility with Vicon®. Conclusion As the system enables a real-time analysis of normal and abnormal gaits of those who wear an artificial lower limb or have knee joint deformity, useful data will be provided to improve gait quality. Keyword Knee Joint, Skin movement, Wearable sensor, Soft tissue artifact, Lower-Limb

Placement of inertial measurement units(IMUs) and optical markers on the legs. The optical markers are

placed at the typical physiological landmarks. The IMUs are attached using body straps

Comparision of the developed IMU-based knee flexion/ extension measurement with the results of Vicon®

Comparision of the developed IMU-based knee flexion/ extension measurement with the results of Vicon®

P60

New Balancing Ability Test Method Using Digital Equipment

Da Hwi Jung1*, Lee Eun Lee1, Tae Sung Park2, Sang Hun Kim1,2, Myung Hun Jang1,2, Myung Jun Shin1,2†, Yong Beom Shin1,2

Pusan National University Hospital, Department of Rehabilitation Medicine1, Pusan National University Hospital, Biomedical Research Institude2

There have been many attempts to measure balance ability for a long time. However, most of the clinical tools are not digitized, and there are many discontinuous ordinal variables that make it difficult to analyze. Therefore, we will test a new balance ability test that can solve these problems simply and quickly. Material and Method A total of 60 healthy people (men; 30) in their 20-30s were recruited to perform a balance test using a new test method and analyzed gender differences between men and women. The new test method was able to evaluate such things as standing still, standing with eyes closed, standing on a mat, standing with eyes closed, standing on a mat, and evaluating static and dynamic balance ability. Sequence 1 2 3 4 Method standing with eyes opened for 30 seconds standing with eyes closed for 30 seconds standing with eyes opened for 30 seconds using Balance Pad(19.7" × 16.1" × 2.4", AIREX®, Switzerland) standing with eyes closed for 30 seconds using Balance Pad(19.7" × 16.1" × 2.4", AIREX®, Switzerland) Results In healthy men, regardless of whether they have mat or not, their balance ability is lower than that of women when they open their eyes. However, when the eyes were closed, the balance of women was observed to fall at a higher rate than men. 1 2 3 4 Men 9.81±4.10 13.06±4.77 9.64±3.15 22.14±7.17 Women 8.22±3.26 13.89±5.32 8.22±2.83 22.95±9.08 Conclusion In this experiment, we found that women were more affected by postural balance than men when the eyes were closed. It is also expected that it will be possible to use it in schools or welfare centers because it is helpful to evaluate the balance ability by being close to the eyes and digital measurement in a short time.

Fig1. Result of FRA balance test

P61

The relationship between muscle parameters and balance abilities by a new device for elderly

Mikyung Cho1*, Myung Jun Shin1†, Tae Sung Park2, Yun Kyung Jeon3, In Joo Kim3

Pusan National University Hospital, Department of Rehabilitation Medicine1, Pusan National University Hospital, Biomedical Research Institute2, Pusan National University Hospital, Endocrinology and Metabolism3

Falls are a major health problem for the elderly and their impact is an important public health issue. One of the causes of falling, sarcopenia is an important health condition. However, it is not easy to measure the muscle mass or function of outpatient clinics by estimate walking speed, grip strength or body composition. Balance test which is a new, easy way to evaluate patients' ability to maintain their posture. The higher the score, the more difficult it was to maintain balance. We evaluated the correlation between muscle mass, function and balance test score. A total of 29 healthy elderly people (men= 14, women=15) in their 70s were recruited to perform a balance test when subjects stands still, and with eyes closed. Sequence 1 2 3 4 Method standing with eyes opened for 30 seconds standing with eyes closed for 30 seconds standing with eyes opened for 30 seconds using Balance Pad(19.7" × 16.1" × 2.4", AIREX®, Switzerland) standing with eyes closed for 30 seconds using Balance Pad(19.7" × 16.1" × 2.4", AIREX®, Switzerland) Grip strength, Skeletal muscle mass index (SMI), leg extension power and gait speed were significantly lower in women (P< 0.001 respectively), and the balance score was significantly higher (P< 0.001). The balance score was significantly higher in women than in men as well as when they opened their eyes (14.3 ± 6.5 vs 10.8 ± 4.1, P=0.036) and closed their eyes. (23.9 ± 10.7 vs 15.8 ± 6.2, p=0.040) In women, the balance score was significantly correlated with grip strength (p=0.024) and the leg extension power (p=0.018), but the correlation disappeared with thy closed their eyes (p=0.152, and p=0.844, respectively). SMI was not correlated with balance score. In men, the balance score was significantly related with SMI, but not with grip strength, and leg extension power with or without eye opening. However, skeletal muscle mass index was significantly correlated with balance score (p=0.033). The balance score was related with muscle function or mass, but the relationship has gender difference. More study is warrant to evaluate the usefulness of balance score.

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Suggestions for Establishing Reasonable Insurance Benefit Standards based on the Questionnaire

Yin-Zhu Xu1*, Jae-Hwa Chung2, Jin-Sil Choi1, Il-Young Jung1, Kang-Hee Cho1†

Chungnam National University, 1Department of Rehabilitation Medicine, School of Medicine1, Chungnam National University, Graduate School of Public Health2

Purpose To reflect the current status of the use of artificial limbs for amputees, and to provide essential basic data for more effectively improving the corresponding health insurance welfare system. Methods The questionnaire survey was conducted for grasping the status quo of prosthetic users in this study. The respondents are those who currently receiving insurance and welfare support from the National Health Insurance Company. With the assistance of agencies an interview questionnaire was conducted for 103 users who used prosthetics. For minors under the age of 19, the guardian agreed to conduct a survey with the guardian. The questionnaire includs personal information, the type of prosthesis currently in use, the purchase of prosthesis, additional expense, the cost of maintenance, satisfaction with the quality of the prosthesis, service expectations et al. Results The statistical analysis showed that 95.15% of the disability causes are posteriority, and 82.47% caused amputation are due to accidents. Among them, men accounted for 83.75% of the population, with the sociodemographic characteristics that men are more likely to be exposed to dangerous accidents such as driving, labor, and sports. The statistical analysis of the situation of prosthetics exhibited that, the proportion of calf prostheses are as high as 45.45%, and 81% of users average daily use time are more than 6 hours. Which suggested that prosthetics play an essential role in walking of the daily life and social activities. However, since the hand prosthesis is aesthetically pleasing only, it is ungently needed to develop a functional hand prosthesis. They all received various kinds of support including National Health Insurance (56.57%) Except 21.21% were paid by individuals for purchase of artificial limbs. And, 71.6% of the person with an extra costs of more than 1 million won, and an average of 667,500 won is required for maintenance, excluding free maintenance every year. 71.11% of the respondents felt that the burden of the additional charge was very heavy, and 65.22% of the respondents were generally satisfied with the quality. This indicated that its support is not high relative to the generalization of insurance benefits. In terms of service improvement, 47.19% of the objects expected to increase the insurance benefits amount, 20.22% expected improve the quality, followed by 16.29% who expected to simplify the procedure, which suggested that the general issue for prosthetics is the economic burden.

Conclusion The study indicated that, the technology in the prosthetic limb area needs to be developed, the quality and service details needs to be improved, and the cost of the prosthetic limbs must be reduced. We think it is most urgently to raise the amount of the insurance benefit standard by considering the price increase and production environment change. Keywords Prosthesis, amputee, questionnaire survey, insurance benefit, improve

P63

Survival Rate according to the Severity of Stroke and Rehabilitation Treatment Intensity in Korea

Dougho Park1*, Han Eol Cho 2, Hyun sun Lim 3, Hyoung Seop Kim4†

Pohang Stroke and Spine Hospital, Department of Rehabilitation Medicine1, Yonsei University College of Medicine, Department of Rehabilitation Medicine2, National Health Insurance Service Ilsan Hospital, Research and analysis team3, National Health Insurance Service Ilsan Hospital, Department of Rehabilitation Medicine4 Introduction Under the only National health insurance system of Korea, we analyzed the survival rate after stroke in both acute and chronic stage depending on rehabilitation treatment intensity (the medical cost and the length of hospital stay) matched with post-stroke severity grade. Methods It was a retrospective cohort study based on nation-wide one million population data. We enrolled 1,025,340 subjects from January 2008 to December 2013 who had a stroke event and underwent post-stroke rehabilitation and finally extracted 7,086 subjects who underwent inpatient rehabilitation therapy. We divided patients into four groups according to the medical cost and the hospital stay in both acute and chronic stage of stroke and analyzed the survival rate in each group. Each group was matched with three severity groups according to the Korean disabled registration after stroke. Cox proportional hazard model was used and every group was adjusted for age and gender. The survival rate of the patients has been followed up to 60 months after the onset. Results As the greater severity of the stroke and the older ages, the longer the hospital stay and the higher medical cost (Table 1, Table 2) in both acute and chronic stages. However, longer hospital stay and higher medical cost showed higher hazard ratio to survival rate in the same severity group (Fig.1, Fig. 2, Fig.3, and Fig. 4). Conclusions These results suggest that stroke rehabilitation in Korea reflects the lack of an effective and systematic delivery system. Stroke patients who are older, have higher severity, or have acute or chronic complications are receiving inpatient rehabilitation, not for returning to family and society. Based on this study, it is necessary to establish an effective rehabilitation delivery system after stroke considering the age, stroke severity, in both acute and chronic phases after stroke.

Table 1. The demographic data of the subjects classified by medical cost in the acute stage

Fig 1. Hazard ratios according to the Medical cost and Severity of the Disability in the acute stage

Fig 2. Hazard radio according to the Medical cost and Severity of the Disability in the chronic stage.

P64

Anorectal Manometry in Spinal Cord Injured Patients: focusing on cough reflex.

Eu-Deum Kim1*, Gi-wook Kim1, Yu-Hui Won1, Sung-Hee Park1, Myoung-Hwan Ko1, Jeong-Hwan Seo1†

Chonbuk National University Hostpital, Department of Physical Medicine and Rehabilitation1, Chonbuk National University Hostpital, Research Institute of Clinical Medicine of Chonbuk2

Objective Spinal cord injury (SCI) patients have anorectal dysfunction resulting in constipation and fecal incontinence. In this study, we aimed to analyze anorectal manometry parameters, especially cough reflex, according to the presence or absence of incontinence and constipation, spinal cord injury levels in SCI patients (cough reflex is involuntary parameter). Method Anorectal manometry was performed on 38 SCI patients who had no anal or colonic disease before the injury. Pressure measurements used the rapid pull-through (RPT) method, and volume measurements used a balloon-tipped catheter. Five pressure indices (resting tone, maximal pressure, mean pressure, squeezing pressure, cough reflex), two sphincter length indices (length of anal canal, high pressure zone length), and one volume index (rectoanal inhibitory reflex) were analyzed. Then, these parameters were compared with spinal cord injury levels and international bowel function spinal cord injury data set. Results Resting tone and squeezing pressure were lower than normal values in SCI patients. Parameters of anorectal manometry in SCI patients were not associated with incontinence, constipation and spinal cord levels. However, squeezing pressure was higher in incomplete SCI than in complete SCI (p=0.005). Cough reflex amplitude was higher in incomplete SCI than in complete SCI (p=0.017) and also higher in injuries above T7 than below T7 (p=0.020) by Mann-Whitney test. Squeezing pressure was moderately correlated with cough reflex amplitude (Spearman correlation-coefficient 0.501, p=0.001). Conclusion SCI patients have abnormal parameters on anorectal manometry. There was no significant relationship between patient’s symptoms (constipation or incontinence) and anorectal manometry parameter. However, there was moderate correlation between cough reflex amplitude and squeezing pressure. We conclude that squeezing pressure (voluntary parameter) could be presumably predicted by cough reflex amplitude (involuntary parameter).

P65

Considerations for the management of scoliosis in pediatric and adolescent spinal cord injuries

Ji Cheol Shin, M.D., PhD1†, Sang Won Hwang, M.D.1*, Sang Hee Im, M.D., PhD1, Min Cheol Ha, M.D.1

Yonsei University College of Medicine, Department of Rehabilitation Medicine 1

Objective Neuromuscular scoliosis is a complex secondary condition of pediatric spinal cord injury that develops in high percent of children whose spinal cord is injured prior to skeletal maturity. The effects of paralysis on growth of musculoskeletal system should be carefully considered in case of pediatric spinal cord injury (SCI). In many studies, significant efforts have been made to prevent spinal cord deformation while maintaining upright posture or maintaining ambulation using orthosis. At 12 years of age, the fulcrum last settles at C5 to C6, where it remains throughout adulthood. Younger children are therefore at higher risk of upper cervical injury and spinal deformity. Therefore this study aims to assess the related factors with the scoliosis in pediatric and adolescent spinal cord injured patients. Method Medical records of pediatric and adolescent SCI patients aged 18 years old or younger, who visited the University rehabilitation hospital during year 2000-2015, were reviewed retrospectively. Only the scoliosis patients who were diagnosed by whole spine radiographs (AP and lateral) were included. Exclusion criteria was the patient with a history of scoliosis or spinal deformity before spinal cord injury. The relevance between scoliosis severity and several parameters such as onset age of injury, etiology of injury, neurological status, ASIA classification, level of spinal cord lesion and functional level were analyzed. Result Total 64 patients (34 males and 30 females) were included in this study and their onset age of injury was 7.65±5.19 years (range 0y-17y 5mo). There was a significant difference between Cobb’s angle values according to onset age, etiology, level of injury, completeness, ASIA classification. Scoliosis occurred more severe those injured at younger age than 12, 18.62’, compared with 8.2’ in those injured later (P<0.05). Complete injury and ASIA classification A showed higher cobb’s angle (P<0.05). In terms of injury caused by the trauma, the Cobb’s angle of sports injured patients was significantly higher than other traumas (P<0.05). Patients with thoracic level injury showed Cobb’s angle 20.72’ which is significantly higher than cervical and lumbar injury patients (P<0.05). Conclusion As subjects with complete cord lesion, thoracic lesion, younger onset age demonstrated more severe scoliosis than other conditions, more careful consideration about spinal care

is needed during rehabilitation treatment of pediatric and adolescent SCI patients with above characteristics.

Cobb’s angle according to several parameters

P66

The Effect of DICAM Gene on Neuroinflammatory modulation in CRPS model using DICAM-knockout Mice.

Donghwi Park1*†, Dae Hee Lee1, Ju Young Cho1, Zeeihn Lee1, Jong Min Kim1

Daegu Fatima Hospital, Department of Rehabilitation Medicine1

Background Although complex regional pain syndrome (CRPS) is described as a single disease, it is usually categorized into two distinct phases: an acute stage of CRPS and a chronic stage of CRPS. In addition to changes in the clinical symptoms and signs, these two distinct stages are accompanied by different biochemical changes in both human patients and mouse models of CRPS. Although the mechanisms of this transition from the acute to the chronic stage of CRPS are still very poorly understood, propagation of neuroinflammation in the peripheral nervous system (PNS) (neuroinflammation by peripheral immune cells, ex. macrophage) to CNS (neuroinflammation by astrocyte and microglia) through a weakened blood-brain barrier (BBB) has been identified as one of the major causes of central sensitization, and has been regarded as one of the causes of the chronic stage of CRPS in previous studies. DICAM, a dual immunoglobulin domain containing cell adhesion molecule, is a type I transmembrane protein is found to be expressed ubiquitously in various organs and cell lines. DICAM is also known to be involved in cell-cell adhesion through direct interaction with αVβ3 integrin, such as in the blood-brain barrier (BBB). In addition, DICAM is known to reduce pro-inflammatory cytokine production in lipopolysaccharide (LPS)-mediated macrophage by modulating macrophage M1 polarization. Although DICAM protein has a positive effect on BBB integrity and anti-inflammatory effects on macrophages, it has not yet been determined how it plays a role in CNS immune cells, such as macrophage and astrocyte. Objective We aimed to investigate the role of DICAM gene in the acute and chronic stage of CRPS, and to investigate the possibility of DCAM gene as a therapeutic target in CRPS. Methods The authors constructed CRPS rodent model involving tibia fracture/cast immobilization using wild-type (WT) and DICAM knock-out (KO) mice to investigate the role of DICAM gene in the acute and chronic stages of CRPS. Behavioral testing, gene expression studies, and immunohistochemistry were performed to compare between two groups (WT vs. DICAM KO) at acute and chronic stages of CRPS. Results In both the acute and chronic stages of CRPS, DICAM KO mice tend to be more painful in behavioral pain tests. Immunohistochemistry and gene expression studies of the spinal cords showed that more severe pain patterns in both acute and chronic stages of CRPS in DICAM KO mice than in WT mice may be due to deteriorated neuroinflammation by

DICAM KO astrocytes through increasing secretion of CXC chemokine ligand 10 (CXCL 10) and inhibition of microglial M2 polarization. Conclusions The loss of the DICAM gene has a negative effect on the modulation of neuroinflammation in the CNS. These results suggest that DICAM gene can be a therapeutic target in CRPS. Further studies will be required to determine whether modulating DICAM gene may be effective in the treatment of CRPS.

Fig 1. The image of bilateral hind paw in CRPS of WT mice (A,C,E,G) and DICAM KO mice (B,D,F,H). There was

no significant differences in hind paw volumes between WT and DICAM KO mice CRPS model.

Fig 2. Real-time PCR data of the spinal cord in both the acute and chronic stages of CRPS using WT and

DICAM KO mice. Real-time PCR data revealed that increased CXCL 10, and decreased mARG1 and mMRC1 in

the spinal cord of the acute and chronic stages of CRPS using DICAM KO mice

Fig 3. Behavioral pain tests in CRPS model of WT mice and DICAM KO mice. There was no difference in

behavioral pain tests in ipsi-lateral hind paw between WT and DICAM KO CRPS mice. However, there were

significant differences in contra-lateral hid paw between WT and DICAM KO CRPS mice.

P67

Diagnostic Usefulness of Infrared Thermography in Carpal Tunnel Syndrome

Jang Woo Lee1*†, Dougho Park2†, Soojin Choi1, Jihyun Park3, Yewon Lee3

National Health Insurance Service Ilsan Hospital, Goyang, Korea, Department of Physical Medicine and Rehabilitation1, Pohang Stroke and Spine Hospital, Pohang, Korea, Department of Rehabilitation2, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, Department of Physical Medicine and Rehabilitation3

Introduction Carpal tunnel syndrome (CTS), most common entrapment peripheral neuropathy, is occurred from compression of median nerve at the wrist. CTS causes various symptoms such as neuropathic pain, sensory impairment, muscular weakness and atrophy in the area of median nerve distribution. The diagnosis of CTS is based on symptoms, physical examination and laboratory and imaging studies. Electrodiagnosis is standard tool because it provides objective, sensitive and reliable findings and also information for severity and prognosis. Recently, ultrasound is widely used, too, because of its portability, high-resolution image, good discrimination of soft tissue, and real-time visualization for guided-injection. Digital infrared thermal imaging (DITI) is also proven for diagnosis of various medical and musculoskeletal conditions, such as breast cancer, diabetes mellitus, acute complex regional pain syndrome, Raynaud phenomenon and etc. The purpose of this study is to investigate clinical usefulness of DITI in diagnosis of unilateral CTS. Materials and Methods All patients confirmed as unilateral CTS by electrodiagnostic study. The degree of neuropathy was classified according to the electrodiagnostic results. The severity of symptom was recorded as numeric pain intensity scale. Via ultrasound, the cross sectional area (CSA) of symptomatic median nerve was measured at proximal carpal tunnel bounded scaphoid laterally and pisiform medially. And we measured the skin temperature of bilateral thumbs, index fingers, little fingers, thenar and hypothenar areas in bilateral palmar hands using digital thermography camera. Patients with (1) symptom in bilateral hands, (2) peripheral artery obstructive disease, (3) systemic diseases such as diabetes mellitus, thyroid diseases, fibromyalgia, rheumatic diseases, systemic infection, and cancers, (4) and other musculoskeletal disorders including hand osteoarthritis, CRPS, peripheral polyneuropathy, cervical radiculopathy and myelopathy, history of previous hand operation were excluded from this research. We analyzed the relationship among the results of electrodiagnosis, symptom severity, CSA of median nerve, and DITI parameters. Results Total 53 patients (11 males and 42 females) were included in this study. The duration and NPIS of symptom are 11.8 ± 12.5 months and 4.9 ± 1.9, respectively. According to electrodiagnostic classification, there were 17 mild, 8 moderate, and 28 severe cases of CTS. The other results of electrodiagnostic study and ultrasound were as Table 1. The skin

temperature between affected and unaffected hands did not show difference (Table 2). Although, there were good correlation among the symptom severity, electrodiagnostic findings, CSA of median nerve, skin temperature was not significantly related to other parameters (Table 3). Conclusion This research suggests that DITI is not correlated with other clinical and laboratory parameters and not useful for diagnosis of unilateral CTS. Table 1. The results of electrodiagnostic and ultrasound parameters

Table 2. The results of infrared thermography

Table 3. Correlation coefficients of symptomatic and examined parameters (p-value)

P68

Needle entry angle to prevent carotid sheath injury for cervical TFESI

Jaewoo Choi1,2*, Du Hoe Ha3, Shinyoung Kwon1,2, Youngsu Jung1,2, Junghoon Yu1,2, MinYoung Kim1,2, Kyunghoon Min1,2†

CHA Bundang Medical Center, CHA University, Department of Rehabilitation Medicine1, CHA University, Rehabilitation and Regeneration Research Center2, CHA Bundang Medical Center, CHA University, Department of Radiology3

Background Cervical Transforaminal epidural steroid injection (TFESI) is associated with the risk of the spinal cord or brain infarction. Although most concerns have been focused on the injection route to prevent injury of vertebral artery, there was no previous study for needle entry angle mainly regarding the carotid sheath. This study aims to suggest the rotation angles of fluoroscopy to bypass the carotid sheath according to vertebral levels for cervical TFESI. Methods From January 2009 to October 2017, patients who underwent cervical spine magnetic resonance image (MRI) were analyzed. In the axial sections of cervical spine MRI, three angles to the vertical line were measured (α: angle not to insult carotid sheath, β: angle for the conventional TFESI, γ: angle not to penetrate carotid artery). (Fig. 1) Results α angles tended to increase for the upper cervical levels (C6-7: 53.3°, C5-6: 65.2°, C4-5: 75.3°, C3-4: 82.3°). Otherwise, β angles for conventional TFESI showed a constant value of 45 to 47 degrees (C6-7: 47.5°, C5-6: 47.4°, C4-5: 45.7°, C3-4: 45.0°). γ angles increase as the higher cervical levels as α angles (C6-7: 25.2°, C5-6: 33.6°, C4-5: 43.0°, C3-4: 56.2°). (Fig. 2) Conclusions The risk of penetrating injury of major vessels in carotid sheath tends to be higher at the upper cervical level. Considering the angle to avoid the carotid vessels in an axial section of CT or MRI in addition to vertebral artery might contribute to safe TFESI procedures.

Fig 1. Measurement of needle entry angle

Fig 2. The measured value of α angle, β angle and γ angle

P69

Assessment of spine following correction of nonstructural component in juvenile idiopathic scoliosis

YongSoon Yoon1*†, Jin Kyung Lee1, Tae Yong Seok1, Kwang Jae Lee1

Presbyteria(Jesus) Medical Center, Department of Rehabilitation Medicine1

Objective The aim of the present study was to evaluate the association between progression of curvature of scoliosis and correction for functional leg length discrepancy (a functional component of scoliosis) in patients with juvenile idiopathic scoliosis(JIS). Methods Medical data of 52 patients (26 females, 26 males) with Cobb angle ≥ 10˚ in radiology -

were retrospectively reviewed. They had different hump angle ≥ 5 in forward bending test for idiopathic scoliosis component, and uneven pelvic level at iliac crest by different

RCSPA (≥ 3) as a factor of functional scoliosis. Their mean age was 79.5 ± 10.6 months. The mean period of wearing FO was 18.6 ± 0.70 months. Results

Cobb’s angle was reduced from 22.03 ± 4.39 initially to 18.86 ± 7.53 after wearing FO. Pelvis height difference and RCSPA difference were reduced from 1.07 ± 0.25 cm initially

to 0.60 ± 0.36 and from 4.25 ± 0.71 initially to 1.71 ± 0.75(p < 0.01) . 1) The Cobb's angle improved significantly from 22.03 ± 4.39 ° before treatment to 19.07 ± 6.88 ° after 9 months and to 18.86 ± 7.53 ° after 18 months. 2) Results were analyzed based on the age of 6 years, the mean Cobb angle was improved in both age groups but patients under 6 years of age have been clinically improved by more than 5 degrees. 3) In analysis based on initial Cobb angle, all parameters which are Cobb angle, RCSPA difference, pelvis height difference, and hump angle were improved in the group with less than 24 °. However, there was no significant improvement for those with more than 25 degrees of Cobb angle initially. Conclusion JIS patient may have functional components and it can be a good managements to identify the factors that can cause functional scoliosis in JIS patients, and it should be managed these functional factors. Foot orthosis are effective in correcting functional factors in the case of pelvic inequality caused by different RCSPA for patients with juvenile idiopathic scoliosis.

P70

Oral prednisolone dose in the rate of radioisotope uptake in patients with CRPS type I after TBI

Jung Joong Kang1*, Seihee Yoon1, Jungin Kim1, Seung Hun Park1, Taehoon Kim1, Jong Moon Kim1†

School of Medicine, Konkuk University, Departments of Rehabilitation Medicine1

Objective We conducted this single-center, retrospective study to compare the treatment effects between a high-dose oral steroid regimen and a low-dose one based on changes in the rate of radioisotope uptake on a 3-phase bone scintigraphy (TPBS) in patients with complex regional pain syndrome type I (CRPS I). Methods Of the patients with CRPS I after traumatic brain injury (TBI), 34 met inclusion/exclusion criteria and were enrolled in the current study. Depending on the dose of steroid therapy, these patients were assigned to 2 groups: the high-dose steroid group (n=14) and the low-dose one (n=20). Then, we compared the severity scores, the Kozin’s classification scores and the rate of radioisotope uptake in a TPBS between the 2 groups. Results There were no significant differences in changes in mean values of severity scores and Kozin’s classification scores at 2 weeks from baseline between the 2 groups (p>0.05). In addition, there were also no significant differences in changes in the rate of radioisotope uptake at 2 weeks from baseline between the 2 groups (p>0.05). Furthermore, there were no treatment-emergent adverse effects such as blood pressure elevation, impaired glycemic control, body weight gain and gastrointestinal disturbances. Conclusions Our results suggest that the low-dose steroid therapy is also effective for the treatment of patients with CRPS I after TBI. It can therefore be inferred that the low-dose steroid therapy would also be considered another treatment option for patients where the occurrence of side effects might be of concern following the high-dose steroid therapy.

Fig. 1. Steroid therapy protocol.

Fig. 2. Severity scores and Kozin’s classification scores.

Fig. 3. The rate of radioisotope uptake on 3-phase bone scintigraphy scans.

P71

Effect of Electromagnetic Stimulation Therapy in Various Approaches; a Pilot Study

Joonhyun Park1*, Junghoon Yu1, KyeHee Cho1, Mi Ri Suh1, JongMoon Kim1, Kyunghoon Min1, MinYoung Kim1†

CHA Bundang Medical Center, Department of Rehabilitation Medicine1

Objectives Recent studies have shown that electromagnetic stimulation therapy (EMT) reduces inflammation and relieve pain in the various pain conditions such as myofascial pain syndrome, neuropathy and arthritis. However, the efficacy of EMT has not been compared according to pain characteristics and applying areas. This study is aimed to investigate the effects of EMT depending on those two variables of pain conditions. Subjects and Methods Patients who were treated with EMT between September 1st, 2017 and February 28th, 2018 were enrolled for this study. Inclusion criteria were as follows; 1) chronic pain lasting for at least 1 month, 2) pain scoring 3 or more in numerical rating scale (NRS), and 3) not relieved pain despite prior physical modality. These subjects then were classified into 2 groups, nociceptive and neuropathic, according to scores marked on pain DETECT, a self-reporting questionnaire. The EMT using biphasic pulse (3 Tesla) of 3-5Hz was conducted for 20 minutes a session, and five sessions a week for 2 weeks. In each session, subjects received EMT at different sites; 1) on joint in case of joint pain, 2) on nerve root with diagnosed radiculopathy, and 3) on tender point in case of pain accompanied by focal tenderness. NRS was evaluated at baseline and after the therapy. Results Twenty subjects met the inclusion criteria and were included in this study. Baseline characteristics of the subjects are summarized in Table 1. In all 20 subjects, NRS pain score decreased from average of 5.7 to 3.7 after EMT (p<0.001). The variance of NRS before and after treatment was greater for neuropathic pain than for nociceptive pain (NRS variance 3.00 vs 0.77, p=0.002). Although not statistically significant, the variance of NRS showed greatest difference when EMT was applied on the tender point (Figure 1). Conclusion This pilot study suggests that EMT could relieve pains of various types, especially those with neuropathic characteristics. Moreover when applying EMT, the physician should try to find the tender points to alleviate pain effectively.

Table 1. Baseline demographics on pain characteristics

Fig 1. NRS according to various pain characteristics and applying sites

P72

The efficacy of adjuvant PDRN intra-articular injection on knee OA compared to HA

Seihee Yoon1*, Jungin Kim1, Jung Joong Kang1, Seung Hun Park1, Jong Moon Kim1, Taehoon Kim1†

School of Medicine, Konkuk University, Departments of Rehabilitation Medicine1

Objective To compare the therapeutic effects of adjuvant polydeoxyribonucleotide(PDRN) and hyaluronic acid(HA) with each intra-articular injection on knee osteoarthritis. Methods Patients with osteoarthritis who feels pain more than 5 points with VAS score and radiologically diagnosed(K-L grade 2~3) were recruited at outpatient clinic. The patients were assessed with Visual Analogue Scale (VAS) score, radiologic evaluation, and Western Ontario and McMaster Universities (WOMAC) score at initial visit and therapeutic outcomes were assessed using VAS score, WOMAC score after 1st, 3rd months treatment. Intra-articular injection procedures were performed under aseptic maneuver(sterilize with povidone-iodine solution, use aseptic drape and glove), and approached superolaterally with knee fully extended. Results The mean age of patients was 67 years old, mean morbidity period was 17 months and mean BMI was 26. (table 1) The patients were divided in two groups with randomized manner and patient group A received PDRN andHA intra-articular injection and patient group B received HA intra-articular injection three times and each injection was performed 1 week interval. There were therapeutic improvement in both group A and B patient after 1st month visits. VAS and WOMAC scores are both decreased in both group A and B. At 3rd month visit group A patients VAS and WOMAC scores showed sustained decrease but patients in group B VAS and WOMAC scores were risen after 1st month assessment. The reduction in pain and functional outcome were statistically significant for both groups. Conclusions Adjuvant PDRN is as effective as HA to improve knee osteoarthritis symptoms and functional outcome. Adjuvant PDRN showed sustained effect on knee osteoarthritis in our study.

Table 1. General feature statistics

Table 2. Clinical outcomes after 1month and 3months for two groups

P73

Effect of Knee Pain after Hip Fracture on Ambulatory Status in Acute Inpatient Rehabilitation

Hee Ju Kim1*, Seong Jae Lee1, Jung Keun Hyun1,2, Seo Young Kim1, Tea Uk Kim1†

Dankook University Hospital, Department of Rehabilitation Medicine1, Dankook University Hospital, Department of Nanobiomedical Science & BK21 PLUS NBM Research Center for Regenerative 2

Objective The aim of this study is to investigate the effect of knee pain after hip fracture surgery on ambulatory status in acute inpatient rehabilitation Methods A retrospective case-control study of 42 patients during postoperative rehabilitation after hip fractures surgery were carried out. Patients were divided into two groups; one group is patients suffering knee pain during the first week of postoperative rehabilitation, and the other group is patients without knee pain. We compared post-operative days (POD) to tolerate gait training in parallel bar and gait training using walker. Results Fourteen patients (33.3%) were suffering from knee pain during the first week of postoperative rehabilitation. According to the types of fracture, incidence of knee pain was more common in intertrochanteric fracture than femur neck fracture (50.0% versus 18.2%; p=0.049; independent t-test). In group of patients with intertrochanteric fracture, there is no significant difference in POD to tolerate gait training in parallel bar and gait training using walker between two groups (12.7±3.3 versus 13.5±3.9; p=0.645; independent t-test, 19.3±5.6 versus 18.0±5.7; p=0.637; independent t-test, respectively). But, in the group of patients with femur neck fracture, there is significant difference in POD to tolerate gait training in parallel bar and gait training using walker between two groups (12.7±3.7 versus 17.5±4.1; p=0.026; independent t-test, 16.8±5.7 versus 24.0±7.3; p=0.040; independent t-test, respectively). Conclusion In patients with femur neck fracture, knee pain after surgery delayed gait training in acute inpatient rehabilitation.

P74

Accuracy of Ultrasound-Guided and Non-Guided Botulinum Toxin Injection into Cadaver Neck Muscles

Yun Dam Ko1*, Myung Eun Chung1†, Dae Heon Song1, Ah-Ra Cho1

St. Paul’s Hospital, College of Medicine, The Catholic University of Korea, Department of Rehabilitation Medicine1

Objective To compare the accuracy of ultrasound-guided and non-guided botulinum toxin injection into the neck muscles involved in cervical dystonia. Methods Two physiatrists examined the six muscles(sternocleidomastoid, trapezius, levator scapulae, splenius capitis, scaleneus anterior, scaleneus medius mucles) in each of six fresh cadavers. Each physician injected dye into one side of each cadaver using ultrasound-guided or non-guided injection procedure. For each injection technique, different color dyes were used. Dissection was performed to identify the results of the injection. The injection procedure was regarded to be ‘accurate’ when the dye was visualized in the target muscle and to be ‘inaccurate’ when it was not seen in the target muscle. According to difficulty of access, six muscles were divided into sternocleidomastoid, trapezius muscles (group A) and levator scapulae, splenius capitis, scaleneus anterior, scaleneus medius mucles (group B). We compared the overall accuracies, the accuracy in each muscle and the accuracies in two groups. Results Overall accuracies of the US-guided and non-guided injections into the neck muscles were 97.22% and 59.72% (p=0.000). For each muscle specific, the accuracies of the US-guided and non-guided injections in the sternocleidomastoid muscle were 100% and 79.17% (p=0.022), in the trapezius muscle were 100% and 75.00% (p=0.011), in the levator scapulae muscle were 91.67% and 41.67% (p=0.000), in the splenius capitis muscle were 95.83% and 59.72% (p=0.000), in the scaleneus anterior muscle were 95.83% and 50.00% (p=0.000) and in the scaleneus medius muscle were 100% and 50.00% (p=0.000). Accuracies of the ultrasound-guided injections into the group A and group B were 100% and 95.83% (p=0.045). Accuracies of the non-guided injections into the group A and group B were 77.09% and 51.04% (p=0.001). There was no significant difference in accuracies between the two physicians (p=0.775). Conclusion Ultrasound-guided botulinum toxin injection into the neck muscles offers significantly greater accuracy over non-guided injection. It is also preferable to perform ultrasound guided injection in not only deep muscles but also superficial muscles.

Ultrasound-guided dye injection into the scaleneus anterior muscle. Intraglandular injectate (arrow) are

shown in this figure. SCM, sternocleidomastoid; SA, scaleneus anterior; SM, scaleneus medius; BP, brachial

plexus.

Dissected cadaver with ultrasound-guided injection (blue and green dye, arrow head) and non-guided

injection (yellow and purple dye, arrow head). Non-guided injection that was incorrectly placed into the

scaleneus posterior mucle. SA, scaleneus anterior; SM, scaleneus medius; SP, scaleneus posterior; BP,

brachial plexus.

Table 1.. Numbers is parentheses indicate number of attempts. p-value between the accuracy of non-guided

and ultrasound-guided injections.

P75

Therapeutic effect of microcurrent therapy in herniated lumbar disc patients with neuropathic pain

Wang Hyeon Yun1*, Jinyoung Park1, Doyoung Kim1, Jung Hyun Park1†

Gangnam Severance Hospital, Department of Rehabilitation Medicine 1

Objective Herniated lumbar disc (HLD) is a disease with a high prevalence rate. The patients usually show symptoms like neuropathic pain such as a tingling sensation on the legs, or numbness. For treatment, various types of therapies are performed including medication, traction, manual therapy, and electrothermal therapy (ultrasound, hot packs, and interference current therapy). This study aims to evaluate the efficacy of microcurrent therapy in patients with HLD presenting neuropathic pain. Methods 1) Patients This is a retrospective short-term cohort study with 33 patients (October, 2016 ~ November, 2017) who are complaining neuropathic pain with HLD findings on magnetic resonance image (MRI). The basic characteristics were reviewed including age, sex, height, weight, body mass index (BMI), diabetes mellitus (DM) history, diagnosis, spinal stenosis, and pain medication. 2) Microcurrent Microcurrent therapy was applied to the neuropathic pain area (paralumbar or lower limb) with a medical device called a PANACELL (Chungam Medical Co, Seoul, Korea). Treatment was conducted for seven minutes per treatment with 0.25~1.00 mA intensity as high as the patients could tolerate via stimulating probe with roller type (Figure 1), and the frequency was 60 Hz with a sine wave pulse. 3) Primary outcome Visual analog scale (VAS) score was used to assess the degree of the pain. The VAS score was checked just before and after the treatment. 4) Statistical analysis A Kruskal-Wallis test, Fisher exact test, and a paired T-test were used for statistical analysis. Results The degree of pain reduction (ΔVAS) was compared according to several sub-groups (diagnosis, stenosis, dermatome area, medication, pain site, and the number of treatments) (Table 1). The ΔVAS according to the diagnosis, stenosis, dermatome area, medication, and pain site was not statistically significant (P = 0.40, 0.96, 0.65, 0.65, and 0.43, respectively). However, the ΔVAS according to the number of treatments (1-2 times, ≥3 times) showed a statistically significant difference (P = 0.04) (Table 1). The basic characteristics of the patients according to the number of treatments showed no statistically significant difference except DM (P = 0.047) (Table. 2). Conclusion There was a significant reduction in neuropathic pain in the group treated more than three times compared to the group treated one or two times. This result suggesting that the microcurrent would have cumulative effect in reducing neuropathic pain. However,

considering the limitation of the small sample size, further accumulation of data is required for more delicate analysis.

roller type probe

Table 1. Pain improvement after microcurrent by several sub-groups

Table 2. Basic characteristics of the patients according to treatment number

P76

The Effects of Whole Body Horizontal Vibration Exercise in Chronic Low Back Pain Patients

Heejae Kim1*, Bumsun Kwon1†

Dongguk University Ilsan Hospital, Department of Rehabilitation Medicine1

Purpose To clarify the effects of treatment process using a 12-week horizontal vibration exercise on pain, lumbar extensor and flexor muscle strength and abdominal and paraspinal muscle thickness, balance, level of function in activities of daily living in chronic low back pain (CLBP) patients compared with vertical vibration exercise. Methods According to the type of exercise, subjects were randomly assigned to horizontal vibration exercise group (HVE) and vertical vibration exercise (VVE) group. All participants performed the exercise program for 30 minutes a day, three times a week for a total 12 weeks. The program consisted of 5 minutes of warming-up exercise followed by 25 minutes of WBV exercise. In HVE, the trials were performed on the horizontal vibration platform that oscillates anterior-posterior plane with amplitude of 48mm in the y-axis. In VVE, the subjects used the vertical vibration platform in the same manner as HVE, except that the vibration treatment they received was vertical axis with a frequency range of 28-34 Hz and amplitude of 2.5-5mm. The primary purpose of this study was to clarify the effects of treatment process for CLBP patients using a 12-week horizontal axis vibration exercise on VAS, ODI compared with the results of vertical axis vibration exercise. The secondary purpose was to evaluate the effects of the lumbar extensor and flexor muscles peak torque, average power and the transverse abdominis, multifidus muscle thickness using ultrasonography, balance parameters in same ways. Results A total of twenty-eight participants completed all the exercise and assessment sessions. In all groups, a significant decrease in VAS scores was showed from 12 weeks that persists until 4 weeks after the intervention. The result of ODI revealed significant reduction effect at 6 weeks of treatment in HVE group and 12 weeks in VVE exercise group. And the standing balance control score, lumbar trunk muscle strength in terms of peak torque and average power significantly increased in both groups. But there were no significant changes of all muscle thickness over time in both groups. In all assessments, the differences between groups over time were not significant. Conclusion There were significant change of VAS, ODI, lumbar extensor and flexor muscle peak torque, average power, balance scores over time in both whole body horizontal and vibration exercise according time but no statistically significant difference between groups according to time. Based on these findings, horizontal vibration exercise is as

effective as vertical vibration exercise in reducing pain, improving the balance ability, and the functional ability associated with chronic low back pain.

P77

Comparison of The Effects of Computerized Cognitive Rehabilitation Programs, Bettercog and Comcog

Goo Joo Lee1*†, Heui Je Bang1,2, Hyun Ho Kong1,2, Hyeunsuk Seo1, Minwoo Oh1

Chungbuk National University Hospital, Department of Rehabilitation Medicine1, Chungbuk National University, Department of Rehabilitation Medicine2

Background A program for training memory and attention of cognitive domains in cognitive impaired patients was developed and distributed. However, a computerized cognitive rehabilitation program containing various cognitive domains has not yet been developed. Purpose The clinical efficacy of the Comcog and Bettercog, newly developed computerized cognitive rehabilitation program, is examined in patients with mild cognitive impairment or dementia. Methods We developed a computerized cognitive rehabilitation program(Bettercog) that can train not only memory and attention, but also abilities such as orientation, calculation, linguistic ability, comprehension ability, spatio-temporal ability, executive function, and responsiveness. In order to enhance the subject's interest, we applied real pictures and animations appropriately and applied game elements. To confirm the effectiveness of the newly developed computerized cognitive rehabilitation program, randomized single blind comparison pilot study was performed on elderly with mild cognitive impairment and mild dementia. A total of 20 cognitive decline patients were divided into Comcog group and Bettercog group by random assignment. All subjects received 12 sessions of computerized cognitive rehabilitation programs for a total of three weeks. In a separate space, an independent clinical psychologist performed the Seoul Neuropsychological Screening Battery(SNSB) before and after treatment. Results 8 men, 12 women, total 20 subjects participated. The average age of the subjects was 74.3 years. There were no significant difference between two groups in baseline age, years of education, MMSE, CDR and SNSB score. In the posttreatment cognitive assessment, patients treated with Bettercog improved their MMSE scores from 19.2 to 21.3, which was statistically significant.(p=0.007) In the memory domain of SNSB, the raw score improved statistically from -1.5 to -1.2.(p=0.007) However, there was no statistically significant difference in the final MMSE, CDR, and SNSB scores between the two treatment groups. Conclusion Through this preliminary study, we confirmed that the newly developed computerized cognitive rehabilitation program(Bettercog) is effective in improving cognitive function.

Twelve cognitive rehabilitation sessions do not have enough time to apply various cognitive rehabilitation contents to patients. It is necessary to conduct a large scale study using computerized cognitive rehabilitation program which has various cognitive contents.

Fig 1. Cognitive training content presented on the Bettercog initial screen

C1

Cognitive Impairment in Patient with Meningitis Following Scrub Typhus

Dong seok Yang1†, Ki hyun Byun 1*, Seong Wook Son1

Ulsan University Hospital, Department of Rehabilitation Medicine1

Introduction A systemic infection, scrub typhus is caused by Orientia tsutsugamushi. Scrub typhus may involve central nervous system like meningitis. The pathologic mechanism of the cognitive impairment in patients following scrub typhus is not clear whether gray matter or white matter is involved. Diffusion tensor tractography (DTT) is an advanced MR tool and can show integrity of the Papez circuit in a 3 dimensional view. Using DTT, several studies reported the association between the integrity of the Papez circuit and cognitive impairment in patient with brain injuries. Herein, we demonstrate that scrub typhus causes injury of neural tracts in Papez circuit in patient with meningitis using DTT, which may help understand the underlying mechanism of cognitive impairment. Method A 70-year old male patient visited our clinics due to poor cognitive function. His medical history showed that he suffered meningitis following scrub typhus 30 years ago. We conducted cognitive function with min-mental status examination (MMSE) and computerized neuropsychological test. We investigated cause of cognitive impairment with probabilistic DTT. Diffusion-weighted imaging data were analyzed using Oxford Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) Software Library. Fiber tracking was performed with probabilistic tractography method based on a multifiber model. The probabilistic tractography routines were implemented in FMRIB (diffusion for 5,000 streamline samples at 0.5 mm step length and curvature threshold of 0.2 corresponding to a minimum angle of 80°). The regions of interest (ROIs) for the Papez circuit were as follows [3]: thalamocingulate tract-the cingulate gyrus (ROI-1), anterior limb of the internal capsule (ROI-2), and the anterior thalamic nuclei (ROI-3); fornix-the mammillary body (ROI-1) and the crus of the fornix (ROI-2); mammillothalamic tract-the anterior thalamic nucleus (ROI-1) and the isolated mammillothalamic tract (ROI-2), and the mammillary body (ROI-3); cingulum-the middle (ROI-1) and posterior (ROI-2) of the cingulum. Neural tracts of the Papez circuit on DTT was shown reconstructed three-dimensionally. Results The score of MMSE was 12 and the neuropsychological results were as follows in table 1. The right thalamocingulate tract was thinned (blue arrow) and the left thalamocingulate tract was discontinued (green arrow).There was absence of the mammillothalamic tracts in the right hemisphere (red arrow). In addition, the anterior columns of the fornix (yellow arrow) in the both hemispheres were injured (Figure).

Conclusions Our study demonstrate that DTT is a useful modality to identify injury of neural tract in the Papez circuit in patient with meningitis following scrub typhus. It may be helpful for mechanism of the cognitive impairment following meningitis.

results of computerized neuropsychological test in patient

Diffusion tensor tractography (DTT) image in patient

C2

Coffin-Siris syndrome 1 with ARID1B mutation causes intellectual disability and language delay

Seung Don Yoo1†, Dong Hwan Kim1, Seung Ah Lee1, Young Rok Han1, Jae Hoon Kim1*, Joo Duk Son1, Keum Sun Hwang1, Young Hwa Choi1

Kyung Hee University Hospital at Gangdong, Department of Physical Medicine & Rehabilitation1

Coffin-Siris syndrome (CSS) is characterized by aplasia or hypoplasia of the distal phalanx or nail of the fifth and additional digits, developmental or cognitive delay, distinctive facial features, hypotonia, hirsutism/hypertrichosis, and sparse scalp hair. Congenital anomalies can include malformations of the cardiac, gastrointestinal, genitourinary, and/or central nervous systems. Incidence of CSS, fewer than 200 individuals with molecularly confirmed CSS have been reported, indicating that the diagnosis is rare. Formal diagnostic criteria for CSS have not been established; however, several key features are useful in making a clinical diagnosis. With the recent detection of heterozygous pathogenic variants in ARID1A, ARID1B, SMARCA4, SMARCB1, SMARCE1, or SOX11., all of them encoding proteins, BAF complex which determined to CSS and types (Table 1). In our case, we confirmed CSS1 by genetic test with brain MR imaging. A 10 month-old female visited our department due to delayed milestones. Korea Bayley Scale of Infants Development showed gross motor 78, fine motor 89, personal-social 100, language 78, cognition 100. GMFCS was Level II, GMFM was goal total 19.48%/ 5 = 38.7. We checked up the progress level every 6 months (Table 2). At 27 months old, the language test using SELSI revealed expression language delayed to 16 months, receptive language delayed to 14 months. Dysmorphic features were found (fig 1) and she did not catch up growth. At 43 months old, we did neuropsychological test for intellectual disability, K-WPPSI-IV which revealed VCI=51, VSI=55, WMI=52 resulted in suggest of moderate mental retardation (FIQ=46). Also, We performed cytogenetics analyse and brain imaging for differential diagnosis. The result which found mutation at exon 2, 538 amino acid converted stop codon in ARID1B, but Wiliams gene and 22 deletion were negative. There were no abnormal findings in brain parenchyme and structures at T2 FLAIR (fig 2). But multimodal MR revealed perfusion defect at Lt hemisphere on Perfusion-Weighted Imaging (PWI) (fig 3) and the involvement of left superior longitudinal fasciculus on Diffusion- Weighted Imaging (fig 4). CSS is characterized by developmental delay, severe speech impairment, distinctive dysmorphic features and agenesis of the corpus callosum. This definition was based on clinical findings and was made before the molecular basis of CSS was well known. We report a patient with diagnosis CSS 1 using clinical features and genetic analysis. Given the known function of ARID1B, the findings indicated that chromatin-remodeling defects are an important contributor to neurodevelopmental disorders and PWI shows perfusion defect in left hemisphere in this case. Multimodal imaging might be useful for diagnosis in CSS 1 cases with speech impairment and intellectual disability.

Table 1. Clasiffication of CSS type

Table2. Growth evaluation

fig 1-4, image for patient features and brain imaging

C3

A case report : Isolated bilateral midbrain infarction in a healthy female adolescent

Ho Eun Park1*, Sang Hun Kim1, Myung Hun Jang1, Yong Beom Shin1†

Pusan National University Hospital , Department of Rehabilitation Medicine1

Introduction Midbrain is a part of brainstem responsible for movement control, arousal, visual processing. Also several nerve fiber tracts and nuclei of the cranial nerves are located in the midbrain. In case of midbrain infarction, due to the anatomical nature of the small vessels, clinicians often infer the causative vessels through ischemic territory and clinical features. The Artery of Percheron (AOP) is known to be a variant of cerebral circulation, a solitary trunk originating from the unilateral P1 segment of posterior cerebral artery (PCA) that supplies to bilateral thalami and midbrain. Ischemic insults at this vessel affect bilateral thalami in most patients and often accompany midbrain infarction. We present an extremely rare case of bilateral midbrain infarction in a healthy 17-year-old female without both thalami involvement and report the mechanism of successful treatment based on neuroanatomical physiology. Case report A 17-year-old female visited the emergency room complaining acute onset drowsiness, gait disturbance, mutism and ptosis. On physical examination, postural instability, rigidity in all limbs and extraocular movement limitations were observed. Stroke-related risk factors and family history were denied by her parents. However, magnetic resonance image (MRI) of brain revealed acute infarction of both midbrain. The right P1 segment was invisible and the right P2 segment was well seen branching from the right PCA. (Figure 1.) She was referred to our rehabilitation clinic on the 3rd day of onset. She showed a slow but reproducible response to stimuli and could ambulate requiring moderate assist. However, on the 7th day of onset, bradykinesia, freezing, rigidity and upward gaze limitation especially got worse. Also, she could obey verbal command by non-verbal expression, while initiation of speech and vocalization was impossible. Considering the location of infarction, presenting symptoms were judged to be the result of impairment of the dopaminergic pathway such as bilateral substantia nigra and red nuclei in addition to the lesion of nuclei of 3rd cranial nerve. On the 14th day of onset, levodopa was tried and she recovered alertness on the day 2 of drug administration. Dramatic effect on Parkinsonism and significant improvement on the trail making test were notable. (Figure 2.) The patient has been maintaining the therapeutic effect improving activities of daily living. Discussion In this case, considering bilateral midbrain infarction sparing both thalami, occlusion is expected to occur only in the branch of AOP that supplies bilateral midbrain. The cause of bilateral isolated midbrain infarction was difficult to figure out but dramatic effects of levodopa on the characteristic symptoms of Parkinsonism were obvious. However, it

was unclear whether dopaminergic agents on mutism due to ischemic injury of periaqueductal gray matter of midbrain are effective. Follow up of her symptoms should be required.

Fig 1. Acute infarction of both midbrain; (A) T2WI; (B) Angiography

Fig 2. Trail making test for the evaluation of performance-based instrumental activities of daily living.

Normative values of peers; set A 25.7 ± 8.8; set B 49.8 ± 15.2

C4

Global Synchronization Index as an indicator for Cognitive Function Changes by tDCS in TBI patient

HoYoung Lee1*, Woo-Kyoung Yoo1, Suk Hoon Ohn1, Kwang-Ik Jung1†

Hallym University College of Medicine, Department of Physical Medicine and Rehabilitation1

Traumatic brain injury (TBI) is a main cause of long-term neurological disability, and therefore is an important medical problem for our society. Non-invasive transcranial direct current stimulation (tDCS) has been used in therapeutic purposes regarding cognitive dysfunction after TBI, by eliciting changes of brain excitability. We report the case of a 77-year-old male, who went through a traumatic brain injury and showed severe impairment of cognitive function (Figure1). After completing 20 sessions of 2mA tDCS over the left dorsolateral prefrontal cortex (DLPFC), he showed improvement in cognitive function. The latest analysis global synchronization index (GSI) assesses synchronization of neuronal signals and low-resolution brain electromagnetic tomography (LORETA) localizes brain electrical activity. We describe the effectiveness of tDCS on the cognitive function and cortical power distribution using these two electroencepha¬lography (EEG) analyzing methods in a patient with traumatic brain injury (Figure2).

fig1

fig2

C5

Multiple cranial nerve palsies as presentation of relapsed Non-Hodgkin’s lymphoma

Ra-Yu Yun1*, Ji Won Hong1, Jae Hyeok Chang1, Yong Beom Shin1, Jin A Yoon1†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction The involvement of the secondary central nervous system (CNS) is a rare but almost always fatal outcome in diffuse large B cell lymphoma (DLBCL). We report a rare case of a DLBCL patient with complete remission who was transferred to rehabilitation department and diagnosed as lymphoma relapse after presentation of multiple cranial nerve palsies. Case report A 73-year-old male presented with 4 weeks of progressive left upper limb weakness, right ptosis, and hoarseness. He was diagnosed as stage IV diffuse large B-cell lymphoma 6 months ago after abrupt dyspnea and right costovertebral angle tenderness. He defied 6 cycles of R-CHOP chemotherapy. A computed tomography (CT) abdomen scan and Positron emission tomography (PET)/CT after chemotherapy revealed complete resolution of primary disease. At the time of his deficits, the brain and cervical magnetic resonance imaging (MRI) showed no evidence of CNS involvement. 3 times of spinal tapping showed no evidence of cerebrospinal fluid (CSF) inflammation and paraneoplasic antibody (Ab) test for possibility of peripheral neuropathy associated with his symptoms were all negative. He subsequently developed incomplete ptosis, internal and external ophthalmoplegia in the right eye, suggestive of right 3rd and 6th cranial nerve palsy (Fig. 1). Even so, as there was no evidence of lymphoma involvement, he was transferred to rehabilitation department for further evaluation. The electrophysiologic study showed sensory dominant polyneuropathy. Video fluoroscopic swallowing test and fiberoptic endoscopic evaluation of swallowing (FEES) showed tracheal aspiration with severe retention. Immobile bilateral vocal cord movement with incomplete closure during FEES were suggestive of laryngeal nerve involvement (Fig. 2). During our admission, aspiration pneumonia occurred and we went ventilator care in ICU. As he was not able to perform self expectoration and consistent saliva pooling inside laryngeal vestibule was observed during FEES, tracheostomy was done. Diaphragm ultrasonography showed a half decreased excursion of right diaphragm movement (1.19/2.55cm) suspicious of right hemidiaphragm paralysis. He was complete ventilator weaning was unattainable thereafter. As his neurologic deficits deteriorated with time, we performed additional brain MRI, posterior fossa to focus on cranial nerve involvement. Finally, thickening and enhancement of left temporal fossa, left cavernous sinus, foramen ovale, right levator palpebra superioris and superior rectus muscles, which suggesting lymphoma involvement. He was transferred to hemato-oncology for additional chemotherapy. Conclusion Invasion of the multiple cranial nerves for a Non-Hodgkin’s lymphoma patient without previous CNS involvement is rarely reported. For our patient, not overlooking of these

progressing symptoms through continuous neurologic examination and appropriate assessment, he was able to proceed on his additional chemotherapy.

Fig.1.Extraocular movement limitation of patient

Fig.2.Incomplete vocal cord closure with tracheal aspiration during FEES

C6

Pharyngeal dystonia misdiagnosed as cricopharyngeal dysphagia treated with pharmacotherapy

Ho Eun Park1*, Je-Sang Lee1, Jin A Yoon1, Ra-Yu Yun1, Yong Beom Shin1†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction The occurrence of dysphagia after stroke is very common. Although pharyngeal functions recover during stroke recovery, cricopharyngeal dysphagia (CPD) tends to remain. However the pathogenesis of focal pharyngeal dystonia caused by stroke is unclear and it hardly ever report. We report a rare case of dysphagia caused by focal pharyngeal dystonia after stroke that was successfully treated through pharmacotherapy. We also discuss a mechanism of a successful pharmacologic approach to central dysphagia. Case report A 43-year-old female was admitted to our rehabilitation clinic complaining excessive drooling and dysphagia. A year ago, the patient underwent coil embolization for SAH due to left vertebral artery aneurym rupture, and she was later confirmed to have lesions of the pons, medulla, and cerebellum due to left PICA infarction on brain magnetic resonance image. Gag reflex was diminished and left vocal cord palsy was confirmed, but the pronunciation and articulation were clear. At 3 months of onset, percutaneous endoscopic gastrostomy (PEG) was performed and there was no improvement after aggressive dysphagia therapy such as neuromuscular electrical stimulation. Activity of daily living was independent, but drooling, voice quality, and dysphagia resulted in significant quality of life deterioration. At 1 year and 2 months of onset, the videofluoroscopic swallowing study (VFSS) showed no progression from the pharyngeal to the esophageal phase. An otolaryngologist diagnosed cricopharyngeus muscle hypertonicity and underwent botulinum toxin injection under general anesthesia, but symptoms did not improve. After 3 months after botulinum toxin injection, on laryngoscopy, focal pharyngeal dystonia was confirmed rather than CPD. For management of dystonia, Trihexyphenidyl 2mg, clonazepam 0.5mg, and gabapentin 100mg three times a day were started to be considered as dysphagia caused by focal dystonia in pharyngeal muscle after brain lesion. Drooling showed a significant improvement in the first week of dosing, and at the 3rd weeks, the bolus transit to esophagus (Figure 1). The patient felt uncomfortable with PEG and removed the tube after orogastric tube training. Failure to take the medication for 3 days due to the loss of drug caused the drooling and food retention, and the washout period was not available due to fear of discontinuation of medication. There is no further improvement, but progress is being made without adverse effects (Figure 2). Discussion In patients with medulla or pons lesions, swallowing disorders have been reported to be particularly ineffective for botulinum toxin injection, suggesting that CP muscle itself is not the only problem. We suggest that pharyngeal dystonia should be considered in

addition to CPD in the case of dysphagia caused by dysinnervation of central nervous system. In addition to VFSS, esophageal manometry and electromyography should be performed to determine the treatment of central dysphagia.

Fig 1. Videofluoroscopic swallowing study according to the time of administration of medication; (A) Before;

(B) After 1 week; (C) After 3 weeks; (D) After 7 weeks

Fig 2. Changes in indices according to administration of medication; (A) Functional dysphagia scale (FDS); (B)

Food intake level scale (FILS); (C) Teacher drooling scale (TDS); (D) Beck depression inventory (BDI)

C7

Paroxysmal Autonomic Instability with Dystonia after Multiple Cerebral Insults : A Case Report

Hyung Nam Lee1*, Yu Hui Won1, Sung-Hee Park 1, Myoung-Hwan Ko1, Jeong-Hwan Seo 1, Gi-Wook Kim 1†

Chonbuk National University Hospital, Department of Rehabilitation Medicine1

Introduction Paroxysmal autonomic instability with dystonia (PAID) is an under-diagnosed syndrome that describes a collection of symptoms after the diverse cerebral insults like traumatic brain injury, hydrocephalus, hemorrhagic stroke, brain anoxia. It is manifested by systemic hypertension, hyperthermia, tachycardia, tachypnea, diaphoresis, intermittent agitation and certain forms of dystonia. Case A semicomatous 46-year-old male presented to the emergency room with fluctuating vital sign such as uncontrolled hyperthermia (39~40.6°C), hypertension (systolic blood pressure 168~190 mmHg), tachycardia (133~155/min), tachypnea (35~48/min) and dystonia in all extremity (decerebrate posture). Patient had a brain surgery for astrocytoma in 1996. He also got a history of a first ischemic stroke on basal ganglia in 2008 and a second one in 2017 on the same area. The lab, EKG and radiologic study were normal. His brain image indicated an old infarction on basal ganglia with hydrocephalus. Tractography using diffusion tensor image technique showed a discontinuity of multiple tracts and electrophysiologic tests like evoked potentials displayed an absent response. Based on his dysautonomic symptoms and brain evaluations, physiatrist diagnosed patient of PAID syndrome. To manage PAID syndrome, propranolol and clonazepam were administered sequentially, but no effects were identified for improving the autonomic instability. Intravenous opioid (IV morphine) was then administered, and his body temperature, heart rate and respiratory rate were effectively controlled and his decerebrate type dystonia subsided. However blood pressure was excessively controlled that severe hypotension occurred as systolic blood pressure below 90mmHg. And then, transdermal opioid (fentanyl) patch was applied, to dose of which equivalent to IV opioid, once in every 3 days for PAID syndrome. Finally all his vital signs and dystonia were managed without any complications and patient was discharged from the hospital. Conclusions We observed the patient with PAID after multiple cerebral insults controlled by applying opioid patch not by intravenous route or oral route. Transepidermal opioid patch such as fentanyl patch can be effective for the patients with PAID after multiple cerebral insults.

C8

Secondary parkinsonism after anterior cerebral artery aneurysm rupture

Eun Gyeom Cha1*, Da Hwi Jung1, Myung Hun Jang1, Jin A Yoon1†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction Various neurological symptoms may occur after acute cerebral aneurysm rupture depending on its specific region. Secondary parkinsonism by increased ventricular pressure near the basal ganglia after cerebral hemorrhage are thought to cause mechanical disruption of dopaminergic system. Symptoms of parkinsonism including bradykinesia, tremor and stereotypy may disrupt functional recovery. It can be controlled by dopaminergic medication, which means accurate diagnosis of secondary parkinsonism is important for these stroke patients. We report a case of parkinsonism after anterior cerebral artery aneurysm rupture with successful management with dopaminergic agent. Case report A 61-year old male patient was admitted with mental deterioration and undergone hematoma removal and external ventricular drain insertion due to subarachnoid hemorrhage after left anterior cerebral artery aneurysm rupture. (Figure 1,2) After surgical treatment, he was transferred to local rehabilitation hospital. He was readmitted 3 months after discharge for percutaneous endoscopic gastrostomy (PEG) after esophageal ulcer induced by repetitive Levin tube irritation and referred to rehabilitation clinic after the intervention. On neurologic examination, he had perfect score at mini mental state examination with some attention deficit observed at computerized neurocognitive test. He had no focal motor or visuospatial deficit. In spite of this neurologic status, he presented severe functional disability due to bradykinesia, impaired oral movement, tongue and palate tremor and uncontrolled stereotypic movement of drawing a circle. He had gait disturbance, unable to express a full verbal sentence, continue oral feeding or remove his tracheostomy. Single photon emission computed tomography (SPECT) images of the brain showed reduction of radioisotope uptake in both caudate and putamen which represented low perfusion in corresponding lesion. (Figure 3) Levodopa (Madopar 250mg P.O TID) was challenged under diagnosis of secondary parkinsonism. Two weeks after medication, his symptom radically improved as he could walk independently, PEG and tracheostomy was removed as improvement of dysphagia and dysarthria. His Unified Parkinson’s Disease Rating Scale declined from 48 to 6. Finally, he showed marked improvement of functional ability at discharge. Conclusion This is a case of successful management of secondary parkinsonism diagnosed 3 months after acute cerebral hemorrhage. Decreased regional cerebral blood flow in both basal ganglia corresponded with his symptoms and the dopaminergic agent had vasodilatory effect on the striatal vessels, increasing local blood flow. This eventually showed marked improvement changing his functional prognosis. If a patient develops clinical features of parkinsonism and those symptoms are not improved even after acute stroke, the

possibility secondary parkinsonism-like syndrome following appropriate management should be considered.

Fig. 1. Brain computed tomography angiography showing left anterior cerebral artery aneurysm rupture.

Fig. 2. Brain computed tomography showing subarachnoid hemorrhage.

Fig. 3. SPECT image showing moderately decreased perfusion at both basal ganglia.

C9

Cases of increased bladder function by temperature differed normal saline bladder irrigation

Na Na Lim1*, Dong Youl Lee1, Ji Hong Cheon1, Geun Su Lee1, Youn Kyung Cho1†, Sung Hoon Lee1, Hyun Kyung Lee1

Kwangju Christian Hospital, Department of Rehabilitation Medicine1

Objectives The use of indwelling urethral catheters, for prolonged period of time is discouraged because there are a various adverse effects including urinary tract infection, bladder stones, urethral injuries and decreased kidney function. Furthermore, discomfort and pain caused by indwelling urethral catheter can be the major concern of the patient. Conventional managements are known as pharmachologic treatment, surgical approaches, behavioral managements. The purpose of the study was to increase bladder function and eventually help patients to self void by non-invasive methods, who failed conventional approaches. Methods The patients' indwelling urethral catheter was changed to new ones and they had bladder

irrigation with two packs of cold normal salines (500ml, 4℃) and two packs of warm

salines (500ml, 20-30℃) alternatively twice a day. Foley catheters were not clamped during the irrigation being afraid of vesico-urethral reflux. Results Results are summerized in Table 1. Conslusion The unmyelinated C fibers exhibit spontaneous firing when they are activated by chemical or cold temperature irritation at the bladder wall and have been found to "wake up" and respond to distention and play an important role in stimulating uninhibited contractions. It is assumed that the temperature differed normal saline bladder irrigation gave patients a beneficial effect by stimulating unmyelinated C fibers. As the procedure is non-invasive, economical and simple trial for the patients who have voding difficulty, larger studies are needed to clarify the clinical role of this trial.

Table 1.

C10

Dysphagia found in the patient who has Vocal cord palsy without CNS lesions

Kyun Yeon Lee1*, Yong Kyun Kim1†, Jung Hyun Cha1

MyongJi Hospital, Department of Rehabilitation Medicine1

Introduction Generally, the main cause of dysphagia is CNS lesions of a stroke. It has been known that dysphagia is triggered by the absence of coordination which is caused by imbalanced function and lowered regulation ability of pharyngeal muscle. Therefore, dysphagia evaluation and treatment are performed in many rehabilitation departments, as well as in this hospital. This case report tries to introduce the dysphagia case caused by the vocal cord palsy which occurred without any CNS lesions and anatomical abnormality. Case presentation This female patient aged 74 has suffered from Dysphagia, Dysphonia since Jan. 2, 2018, and had evaluation examinations including Brain MRI at a local hospital. However, there were no special opinions. On Jan. 22, 2018, her symptom got worse and lasted, and she came to be hospitalized in this department via ER of this hospital. According to the VFSS conducted on Jan. 23, 2018, she was found to have semisolid remnant 50% and Liquid 8cc during swallow aspiration. In such examinations as Brain MRI, Brain MRA, and Neck MRA conducted on the same day, no special opinions were found. In Neck CT, Chest CT, and EGD which were conducted to identify any anatomical abnormality, no special opinions were observed. In the joint treatment of otolaryngology, Rt. vocal cord palsy was observed on otolaryngology. After Rt. vocal cord Restylene injection was performed on Jan. 26, 2018, vocal cord palsy was improved. VFSS f/u was conducted again. As a result, Semisolid remnant reduced to 30%, and Liquid 8cc non aspiration was observed. Therefore, home discharge was offered under oral intake. Conclusion This patient had Dysphagia, Dysphonia suddenly without any CNS lesions and anatomical abnormality. After the treatment of vocal cord palsy, the symptom was improved and she was discharged from hospital. As the causes of vocal cord palsy that occurs out of sudden, there are Surgery complications, Neck injury, Stroke, and Tumors. However, such causes were not found in this patient, and her possible cause was subclinical viral infections. After viral infections which occurred for unknown causes, she had vocal cord palsy which triggered Dysphagia. After the simple treatment of Filler injection, Dysphagia was treated. Therefore, when a patient with Dysphagia is hospitalized, it is necessary to take into account the possibility of vocal cord palsy without CNS lesions and to solve the problem if it occurs.

Fig 1. Rt. vocal cord palsy (Initial)

Fig 2. Post Restylene injection

C11

Familial agenesis of corpus callosum with MCI in maternal inheritance: cases report

Jae Wan Yoo1*, Seong Hoon Lim1†, Bo Young Hong1, Joon Sung Kim1, Bo Mi Sul1, Hee Won Lee1, Won Jin Sung1, Jung Jae Lee1

St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Department of Rehabilitation Medicine1

Introduction Formation of the corpus callosum is related to a complex process involving several proteins. Mutations in many genes cause malformations in development of the corpus callosum, which associate with various phenotypes such as language and intellectual disabilities, motor impairment, and epilepsy. We present a familial corpus callosum agenesis case with intellectual disability. Case report A 55-year-old female patient went to the emergency room for right side weakness and performed brain Magnetic Resonance Imaging (MRI) on August 5, 2009. MRI findings revealed acute infarction of the left centrum semiovale region. However, the patient showed cognitive deficits that are significantly decreased compared to the location and size of cerebral infarction found on brain MRI. Thus, we suspected that the prominent cognitive deficits were more related to corpus callosum agenesis detected on brain MRI (Fig 1-A). Brain MRI. On the physical examination, Mini Mental Status Examination (MMSE) was checked as 16 points which were degraded in the orientation, registration, recall, and attention and Global Deterioration Scale (GDS) checked as 5 points. The patient could gait independently with monocane. Toileting and bathing could also be performed independently in activities of daily living. Modified Barthel Index Score (MBI) score was checked as 64. On the neurologic examination, dysarthria is revealed but no abnormal findings were found in other examination including electroencephalography (EEG). Then, during follow-up from the outpatient clinic, the daughter accompanied by the patient and also revealed minimal cognition impairment (MCI). Under suspicion of neurological disorders, further radiographic evaluation was performed to confirm suspected brain lesion (Fig 1-B). MRI findings revealed corpus callosum agenesis, diffuse colpocephalic appearance of both lateral ventricle and possible subarachnoid cyst of both temporal fossa, similar to the findings of her mother. On the physical examination, both upper and lower extremities are checked as normal grade of MMT. On the neurologic examination, MMSE was revealed as 18 points, Montreal Cognitive Assessment (MOCA) as 15 points and Global Deterioration Scale (GDS) as 5 points. Conclusion In this case, we report a familial corpus callosum agenesis with minimal cognition impairment in maternal inheritance. Further genetic analyses such as karyotype analysis, array CGH study and DNA sequencing (e.g. for Mutations in DCC) are needed to better

investigate the molecular processes leading to corpus callosum agenesis and to achieve proper genetic counselling.

Fig 1. Magnetic resonance imaging showed agenesis of corpus callosum. A. MRI of mother, B. MRI of

daughter.

C12

Combined Congenital Muscular Torticollis and Congenital Vertebral Anomaly : A Case report

Dae-Hyun Jang1*†, Da-Ye Kim1, Dong-Woo Lee1, Jung-Ro Yoon 1

Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Department of Rehabilitation Medici1

Case description A one-month old female infant was suspected of having muscular torticollis and referred to our hospital from the local clinic. Physical examination showed mass on her right neck, which was consistent with congenital muscular torticollis. Ultrasonography of neck showed diffuse enlargement and hyperechoic findings on the affected side of sternocleidomastoid muscle (Fig. 1). To confirm an associated fracture, the clavicle x-ray was taken but there were no specific findings on the radiologist’s reading (Fig. 2). Although the clavicle x-ray was non-specific, cervical spine x-ray and 3-dimensional computed tomography were taken because the bony abnormalities were not completely ruled out. The images showed T1 butterfly vertebra (Fig 3). Discussion To the best of our knowledge, this is the first case report of congenital muscular torticollis and vertebral anomaly were accompanied. It is not clear either vertebral anomaly affects the occurrence of the congenital muscular torticollis or the two congenital defects occur just co-incidence. Although it is difficult to make sure the pathogenesis of the concurrent defects, vertebral anomaly should be considered even in patients diagnosed with congenital muscular torticollis.

Fig 1. Ultrasonography showed diffuse enlargement and hyperechoic findings in right sternocleidomastoid

muscle.

Fig 2. Clavicle X-ray was read by radiologist as non-specific findings.

Fig 3. Cervical spine X-ray (A) and 3-dimensional computed tomography (B) showed T1 butterfly vertebra.

Axial cervical CT showed an enlargement of SCM muscle (arrow) at C7 level (C) and a butterfly vertebra

(arrow) at T1 level (D).

C13

Management of Non-traumatic Atalanto-axial Subluxation; Grisel's Syndrome in Children

Minji Jung, MD1*, In Young Sung, MD1†, Eun Jae Ko, MD1

Asan Medical Center, University of Ulsan College of Medicine, Department of Rehabilitation Medicine 1

Purpose Grisel syndrome is a non-traumatic atlantoaxial subluxation and a rare complication of any inflammatory condition defined as an atlanto-axial instability from inflammatory ligamentous laxity in the head. Delayed diagnosis causes neurological impairment, ranging from radiculopathy to paralysis and death. Methods Records of pediatric patients diagnosed radiologically and clinically with AARS between January 1998 and January 2018 were retrospectively reviewed. Of 173 patients identified, 159 were traumatic AARS and 14 were non-traumatic AARS. Only 5 out of 14 patients were classified as Grisel syndrome. 1 were male and 4 were female on average 7.2 years of age (range 4–11 years). Results Causes of Grisel’s syndrome included retropharyngeal infection (N=3), mucocutaneous lymph node syndrome (N=1), upper repiratory infection (N=1). Symptom duration varied: 3 patients who diagnosed AARS in early stage and recovered only with antibiotic therapy had symptoms for 11 days (range 8-12 days), 2 patients who began halter traction treatment 25 days and 30 days after AARS diagnosis respectively had symptoms for 117.5 days. In 1 patient halter traction management failed and required halo vest to reduce the subluxation for 3 months. In 1 patient underwent initial halter traction, but after 25 days of symptom resolved, subluxation progressed again. 13 days of halter traction was placed additionally, and Minerva orthosis was applied for 1 month to make sure resolution of AARS. Conclusion Grisel’s syndrome remains a rare, but potentially lethal children condition. Patients presenting acutely without neurological deficits can likely undergo antibiotics and collar therapy; those in whom the subluxation cannot be reduced may require traction and/or halo vest or Minerva orthosis. Early diagnosis with appropriate treatment is crucial to its management and prognosis.

C14

Clinical characteristics of 14q11.2 microdeletion in Korean children with developmental delay

Kye Hee Cho1*, Joonhyun Park1, Sung Han Shim2, MinYoung Kim1†

CHA Bundang Medical Center, Department of Rehabilitation Medicine1, Fertility Center, CHA Gangnam Medical Center, Genetics Laboratory2 Introduction Multiplex ligation-dependent probe amplification (MLPA) assay is considered as the gold standard for detection of copy number variations including microdeletions/duplications. However, accurate detection using MLPA is technically challenging due to restricted number of DNA probes that can be examined among multiple genomic regions, and the high cost of chip-based assays. In 49 children with developmental delay/ intellectual disability who had normal MPLA results between 2011 and 2016, microarray-based Comparative Genomic Hybridization (aCGH) was applied. As results, cytogenetic aberrations were identified in 35 patients including eight patients with microdeletion at 14q11.2. Four patients had a single microdeletion at 14q11.2, whereas the other four had combined cytogenetic abnormalities. The common region of microdeletion between 225,337,51 and 229,593,62 bp did not overlap with the previously reported critical region of 14q11.2 deletion between 20,896,740 bp and 20,931,826bp from Canadian aCGH study of children with developmental delay. The common features in Korean children are described for the specific loci of 14q11.2 microdeletion. Clinical Manifestations All patients had intellectual disability mostly in profound degree and growth retardation: height was between 25% and 50% in four patients, 10% and 25% in one, less than 3% in two at ages older than three. Most patients, except patient 4, were born at full term. Patient 5 had received growth hormone replacement therapy for short stature; however, weighted 25kg at 23 years due to poor oral intake. Common features in children with a single 14q11.2 deletion include autism, profound intellectual disability with relatively mild motor dysfunction. Those with additional cytogenetic aberrations tend to be severer motor dysfunction that most cannot walk (Table 1). Discussion The loci of the microdeletion in most patients were in close vicinity and similar in size between 42kb to 60kb. The region of microdeletion shared in most patients contains 10 RefSeq genes (Fig.1, Table 2) including nuclear genes encoding mitochondrial components, OXA1L and MRPL52. OXA1L codes mitochondrial inner membrane insertase that interact with both mitochondrial inner membrane and mitoribosome. MRPL52 codes mitochondrial ribosomal protein L52, a component of a mitoribosome large subunit. Oxidative phosphorylation essential for ATP production takes place in the mitochondrial inner membrane. The defects of genes encoding mitochondrial proteins are particularly interesting as the association of mitochondrial dysfunction and autism has been introduced. Only a few mutations of mitoribosome proteins have been identified for protein synthesis machinery. The translation of proteins to the mitochondrial inner

membrane is an important part of oxidative phosphorylation that abnormal translation may be related to the clinical features of 14q11.2 deletion. Table 1. GA, gestational age; BW, birth weight; Wt, weight in percentile; HC, head circumference; GMFCS,

Gross Motor Function Classification Systems; abn, abnormal; bMRI, brain MRI; EEG,

electroencephalography; NA, not available; m, on antiepileptic drugs; Underlined number patients have

14q11.2 microdeletion only. GMFCS levels and IQ were scored at ages over five years. IQ scores are based

on Munich Functional Developmental Diagnostics unless otherwise stated. Spasticity is based on modified

Ashworth scales (MAS): + = grade ≤ 1+, ++= grade ≥2 *based on Korean Wechsler Preschool and Primary

Scale of Intelligence-IV †based on Korean Wechsler Adult Intelligence Scale-IV

Table 2.

Fig1. Loci of microdeletion at 14q11.2. Patients in blue color had combined genetic aberrations whereas

patients in red had a single microdeletion at 14q.11.2. The location of each gene within the common region

of microdeletion are depicted in yellow column.

C15

Cervical spine malformations with 5q34-5q35.2 micro interstitial deletion: case report

Heewon Lee, MD.1*, Bo young Hong, MD., Ph.D.1†, Joon Sung Kim, M.D., Ph.D.1, Seong Hoon Lim, M.D.,Ph.D. 1, Bo Mi Sul M.D.1

St.Vincent Mary’s Hospital, Department of Rehabilitation Medicine1

Introduction In our report, we identified a proband with a ‘de novo’ 5q34-q35.2 deletion. The purpose of this report is to present a unique clinical phenotype such as skeletal anomaly in cervical spine and reviewed possible related genotype. Case report A 4-years-old girl visited our rehabilitation clinic for development delay. She was born at 39 weeks of gestation with a birth weight of 2,000g. She underwent cardiac septal defect surgery at 2 months and hospitalized for feeding and respiratory disorders for 7 months. On physical examination, she had dysmorphic features with microphthalmos, decreased visual and hearing acuity, so that she applied an artificial eye and hearing aids. Developmental milestones were markedly delayed. Holding up of head were recognized at 12 months, while creeping and crawling at 3 and 4 years respectively, and she could not stand up at 4 years of age. Chromosome 5q34-5q35.2 micro interstitial deletion was diagnosed by Fluorescent in situ Hybridization. Further genetic testing for Prader Willi syndome, Angelman syndrome and spinal muscular atrophy proved negative. A notable symptom was persistent head tilting, which has previously been considered to be associated with symptoms of hypotonia. However, she also had a limitation of range of motion of head rotation. Under suspicion of musculoskeletal disorders, we performed further radiographic analysis. Cervical plain radiographs showed abnormal tube-like structures in posterior C5 [Fig 1] and whole body spine plain radiographs demonstrated thoracolumbar scoliosis [Fig 2]. Non-enhance cervical spine 3 Dimensional Computed Tomography (3DCT) revealed that a bone cleft in the right pars interarticularis, a bone defect in both lamina of C5 and agenesis of the right articular process of C5, which associated with bony fusion of C4-C5. Subluxation in craniocervical joints was also showed in cervical spine 3DCT. An additional focal bone defect in transverse foramen caused inferior bony protrusion and right foramina stenosis at C2-3 [Fig 3]. Bayley Scales at 41 months suggested cognitive, receptive communication, expressive communication, fine motor, and gross motor skill equivalents of 5, 2, 3, 5, and 7 months, respectively. Total score of Gross Motor Function Measure (GMFM) at 41 months was 29% and her GMFCS level was 4. Her speech was limited to simple vocalization without meaning. Despite the intensive rehabilitation therapy, her developmental abilities were significantly delayed at 5 years 10 months of age. Conclusion Several deformities of cervical spine in this patient has not been previously described in the 5q deletion encompassing MSX2. MSX2 has been known as involved in the processes

of limb, craniofacial formation. Based on review with 5q related patients, MSX2 gene could be proposed as candidates for skeletal anomaly involving cervical spinal abnormalities. Molecular studies are required to identify the genotype-phenotype correlation of this deletion.

Fig 1. Cervical X-ray showed abnormal tube-like structures in posterior C5.

Fig 2. Whole body spine plain radiographs demonstrated thoracolumbar scoliosis.

Fig 3. C-spine CT revealed bone defect in both lamina of C5 ,agenesis of the right articular process of C5

with bony fusion of C4-C5.

C16

Vanishing White Matter Disease Associated with a Novel Heterozygous EIF2B3 Variants using NGS

Sung Eun Hyun1*, Byung Se Choi3, Dae-Hyun Jang4, Ja-Hyun Jang5, Ju Seok Ryu2†

Seoul National University Hospital, Department of Rehabilitation Medicine1, Seoul National University Bundang Hospital, Department of Rehabilitation Medicine2, Seoul National University Bundang Hospital, Department of Radiology3, Incheon St. Mary`s hospital, The Catholic University of Korea, Department of Rehabilitation Medicine4, Yongin, Green Cross Genome5

Vanishing White Matter disease (VWM) is an autosomal recessive disorder caused by pathogenic mutations in any of the genes EIF2B1-5. These genes encode the 5 subunits of eukaryotic translation initiation factor 2B (eIF2Bα-ε), of which role is limiting global rates of protein synthesis from messenger RNA translation under stress condition. Therefore, any dysfunction of eIF2B, pathogenesis of VWM, results in stress-provoked episodic rapid neurological deterioration, followed by chronic progressive disease course. We describe a patient with infantile onset VWM of pre-described specific clinical course, subsequent neurologic aggravation induced by each viral infection and finally in a coma state without any response by external stimulus. Although the initial brain magnetic resonance imaging could not reveal specific pathognomonic sign of VWM to differentiate from many other demyelinating leukodystrophy, the next generation sequencing (NGS) study revealed heterozygous missense variants in EIF2B3, including a novel variant in exon 7 (C706G) as well as 0.008% frequency reported variant in exon 2 (T89C). Therefore, the unbiased genomic sequencing can have clinical impact in the patient care and decision making with the genetic disorders affecting white matter in pediatrics.

Fig 1. Magnetic resonance imaging of brain at the patient’s 20 month old (A-B) and 28 month old (C-F). The

T2-weighted image (A, C) shows the diffuse hyperintense abnormality of deep cerebral white matter

spreading to whole white matter. The FLAIR image (B, D) shows that more parts of the abnormal white

matter have a low signal intensity in D than B, similar to cerebrospinal fluid, indicative of progressive cystic

degeneration. Within the abnormal white matter lesion, a pattern of radiating stripes is revealed suggestive

of remaining tissue strands. The DWI (E) and ADC map (F) shows restricted diffusion around white matter

lesion, indicative of ongoing spreading and active demyelinating process within the white matter.

Fig 2. Variants in the eIF2B3 gene in the patient. (A) a novel variant c.706C > G/p.Gln236Glu (B) a rare

variant c.89T > C/p.Val30Ala.

C17

Congenital mirror movements : Ten-year follow-up of transcranial magnetic stimulation(TMS) study.

Eu-Deum Kim1,2*, Gi-wook Kim1,2, Yu-Hui Won1,2, Myoung-Hwan Ko1,2, Jeong-Hwan Seo1,2, Sung-Hee Park1,2†

Chonbuk National University Hospital, Department of Physical Medicine and Rehabilitation1, Chonbuk National University Hospital, Research Institute of Clinical Medicine of Chonbuk National University – Biomedical Research Institute of Chonbuk National University Hospital2

Introduction To our best knowledge, there are few studies about existence of ipsilateral motor evoked potentials(iMEP) of proximal arm and forearm muscles in congenital mirror movement patients. In this report, however, we performed 10-year follow-up TMS study not only in distal hand muscles, but in forearm, proximal arm and lower extremity muscles to clarify their tendency. Case report An 19-year-old boy presented with mirror movement since he was infant. He was a full term baby and there was no noticeable family history. He presented gross motor developmental delay and mild mental retardation. He has no other congenital deformity. We performed follow-up hand function test which showed improvemet of the score even though mirror movent persist. In the Nine-Hole Peg Test, the score was 26 seconds (normal: 16.41±1.65sec) for the right hand and 26 seconds (normal: 17.53±1.73) for the left hand. In this patient, we performed TMS study almost every other year during 10 years, since he was 9. Recordings of ipsilateral and contralateral MEPs(cMEP) were made with bilateral distal hand muscles (first dorsal interosseous muscle, FDI muscle), forearm muscles (extensor carpi radialis, ECR), proximal arm muscles (biceps brachii, BB and deltoid) and lower extremity muscles (tibi¬alis anterior, TA, gastrocnemius, GCM, vastus medialis,VM). The follow-up iMEP/cMEP ratio was more than 1 in the FDI muscle like the past results. Similar pattern was shown in the ECR even though iMEP/cMEP ratio was smaller than those in the FDI muscle. In contrast, iMEP/cMEP ratio was lower than 1 in the BB and the deltoid. There were no ipsilateral motor evoked responses in lower extremities. Discussion This study is a long term follow-up TMS study in a congenital mirror movement patient to investigate motor organization in distal hands, forearms, proximal arms and lower extremities. In conclusion, this case report indicates that motor organization patterns of proximal arm muscles might be different from those of distal hand and forearm muscles even in the same upper extremity. In addition, the mechanism of menifestation of iMEP is different between mirror movement patients and hemiplegic cerebral palsy patients. Moreover, motor organization patterns of lower extremities seem to follow the same pathway with those in normal children.

C18

Novel Compound Heterozygous Mutations in ATM in Ataxia-Telangiectasia: A Case Report

Hyun Jung Kim 1†, Cha Gon Lee2, Joon Woo Kim1*

Nowon Eulji Medical Center, Eulji University, Department of Rehabilitation Medicine1, Nowon Eulji Medical Center, Eulji University, Department of Pediatrics2

Introduction Ataxia-telangiectasia (A-T) is a rare autosomal recessive inherited progressive neurodegenerative disorder, with onset in early childhood. The average prevalence of the disease is estimated at 1/100,000 children worldwide. To date, the prevalence of A-T in the population of the Republic of Korea is suggested to be extremely low, with only two cases genetically confirmed thus far. Case report A 5-year-old boy visited with a chief complaint of progressive gait unsteadiness since the beginning of independent walking at 12 months of age. His perinatal and neonatal histories were unremarkable. He was the third child of healthy, non-consanguineous Korean parents. The family history was unremarkable for neurodegenerative disease. He had no history of recurrent infectious diseases. Upon physical examination, he exhibited normal growth with relative macrocephaly. Ocular telangiectasia was observed but not obvious. Neurological examination revealed no nystagmus or oculomotor apraxia. He exhibited progressive slurred speech, progressive gait and truncal ataxia, choreoathetosis, and both ankle plantar flexor and extensor spasticity with normal muscle strength. Babinski sign was not shown, and deep tendon reflex was not elicited. He exhibited a mild intellectual disability with a Full Scale Intelligence Quotient of 61, as measured by the Korean-Wechsler Preschool and Primary Scale of Intelligence. Serially checked brain magnetic resonance imaging suggested diffuse cerebellar atrophy with enlarged cerebellar sulci and compensatory dilation of posterior fossa. Serum immunoglobulin levels were all within normal limits. His alpha-fetoprotein level was markedly elevated (182.4 ng/ml, normal range < 10 ng/ml). G-banding of chromosomes from the patient’s peripheral blood lymphocytes was normal (46, XY). Genomic DNA was extracted from patient’s peripheral blood leukocytes, and sequencing was performed on an Illumina NextSeq500 platform (Illumina Inc., San Diego, CA, USA) at Green Cross Genome (Yongin, Republic of Korea). We identified and confirmed two novel heterozygous variants of ATM, a c.5288_5289insGA (p.Tyr1763*) and a c.8363A>C (p.His2788Pro) mutations, by Sanger sequencing in the patient and his parents. His father was heterozygous for the c.5288_5289insGA (p.Tyr1763*) mutation, and his mother was heterozygous for the c.8363A>C (p.His2788Pro) missense mutation. Conclusion We report a Korean boy with clinical features including progressive gait and truncal ataxia, choreoathetosis, dysarthria, spasticity of both ankles, and mild intellectual disability. He was identified as two novel compound heterozygote mutations. Patients exhibiting

possible diverse clinical features during early childhood should be considered for A-T. Early genetic analysis using a multigene panel, including ATM, is recommended for early and accurate diagnosis. Our results thus expand the spectrum of mutations and phenotypes in A-T.

C19

Very Early Use of Hand Orthosis for the Treatment of Finger Flexion Deformity in a 1-month-old Child

Eun Jae Ko1*, In Young Sung2†, Baek Hee Jang 1, In Jin Yoon 3

Ulsan University Hospital, University of Ulsan College of Medicine, Department of Physical Medicine and Rehabilitation1, Asan Medical Center, University of Ulsan College of Medicine, Department of Rehabilitation Medicine2, Asan Medical Center, Department of Rehabilitation Medicine3

There are some problems caused by flexion finger deformity; difficulty in hand opening, precise finger movements and activities of daily living. Treatments of flexion finger deformity include stretching exercise, hand orthosis, and surgery. However, there are no protocols set up, especially in a very young child. The objective of this report is to describe the early use of hand orthosis for the treatment of finger flexion deformity in a 1-month-old child. A 30-days-old baby in NICU had a consultation with the Pediatric Rehabilitation Medicine for both hand deformity. He was born at GA 37+3 weeks, 3270g, by caesarean section, He had no family history, and he was the 2nd child. First child was 5 years old who was healthy. Physical examination at 30 days showed head lagging with traction reaction, increased muscle tone at both shoulders, elbows, wrists, and fingers (right > left), and both finger flexion deformity (right > left) (Fig.1). Assessments included: 1) both finger flexion deformity, 2) dysphagia, 3) apnea d/t r/o congenital hypoventilation syndrome, 4) mild hydrocephalus, 5) hydronephrosis, hydroureter Gr2 (both), and 6) left hydrocele. Bedside PT, bedside swallowing therapy, and both hand orthosis (Fig. 2) were prescribed. There was no abnormality in tandem MS, chromosome karyotype, and mitochondrial gene mutation. Diagnostic exome sequencing was done and the result is pending. Brain MRI showed enlarged left lateral ventricle. After discharge, he underwent rehabilitation treatments and kept on using hand orthosis, and his finger flexion deformity became flexible and showed improvements. However, he had developmental delay (Table 1). This case shows improvement of the patient’s flexion finger deformity with early use of hand orthosis and rehabilitation treatments. For young patients with flexion finger deformity, early treatment is very important for better outcome, and very early use hand orthosis should be considered as one of the treatments.

Fig. 1 Both finger flexion deformity at 30-days-old

Fig. 2 Both hand orthosis at 30-days-old

Table 1. Results of a Korean Developmental Screening Test for Infants and Children

C20

Speech pair therapy improve sociality in developmental disorder of speech and language children

Jung Hyun Cha1*, Yong Kyun Kim1†, Kyun Yeon Lee1

MyongJi Hospital, Department of Rehabilitation Medicine1

Introduction As a type of communication disorders, speech and language disorder leads to delayed speech and language learning because of deficiency in cerebral physiological process to understand and express spoken language, and shows a significant deviation from the normal process of speech and language learning. Speech and language disorders in children include deficiency in communication between children, deficiency in the process to understand and express other people’s spoken language in their cerebral and central nervous system, and deficiency in the physiological process to speak language. Typical disorders of speech and language are developmental disorder of speech and language, dysarthria, voice disorder, fluency disorder, and reading disorder. This study aims to look into children with developmental disorder of speech and language, and to find the influence of speech pair therapy on sociality. Methods The study subjects are 10 children who had been hospitalized in department of rehabilitation and physical medicine from Feb. 2016 to Feb. 2018 and were diagnosed with developmental disorder of speech and language. Inclusion criteria are 1) age of less than 8 years, 2) more than 6 months of delayed speech in language evaluation, and 3) the patient group which has less than 80 points in SQ. Exclusion criteria are 1) delayed speech caused by other diseases, 2) rejection of pair therapy, and 3) attention difficulty impeding pair therapy. In case of speech and language therapy, generally one therapist-to-one child matching occurs. In this study, children with the disorder who have similar language ability were paired and therefore 1-to-2 pair therapy was performed. This therapy was performed once a week, a total of 20 sessions. The children cooperated through competition or with the same goal in a game, or did role-play. This program induced dialogues necessary to each other. Before this pair therapy was performed, language evaluation was conducted with PRES examination and paired the children with a similar level. Through SQ, their sociality was evaluated. After the end of the therapy, SQ, and PRES examination were reevaluated to find any changes in sociality, language skills and communication. Results 10 children with developmental disorder of speech and language showed significant rises in SQ score. Their language evaluation was also significantly improved. Conclusion Speech pair therapy not only improved the language skills of the children with developmental disorder of speech and language in a similar level, but also contributed to

their sociality improvement by way of creating the relationship between the children of their age. Developmental disorder of speech and language makes social interaction more difficult resulting decrease in sociality. Through this pair therapy, it may be possible to improve the sociality of pre-school children by practicing speech with other children of their age and thereby to get along well with other st

C21

Stiff Person Syndrome With an Evidence of Polymyositis Secondary to Sustained Muscle Contraction

Seung-Wook No1*, Du Hwan Kim1†, Du Hwan Kim1†

Keimyung University Dongsan Medical Center, Department of Rehabilitation Medicine1

Introduction Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by progressive muscular rigidity and spasms that affect axial and limb muscles. There have been a few reports that patients with SPS had evidences of polymyositis (PM). There have been no clear explanations about the characteristics of PM in SPS. We report a case of SPS with an evidence of PM secondary to sustained muscle contraction that partially responded to immunomodulatory agent. Case A 36-year-old woman presented with a 1-year history of progressive rigidity and pain in her proximal upper and lower limbs. Her medical history revealed idiopathic chronic kidney disease diagnosed 3 years ago and depression for 15 years. Physical examination revealed normal deep tendon reflexes and absence of motor and sensory impairment. Sustained contraction of the trapezius, biceps, triceps, quadriceps, and hamstring muscles during rest was prominent (Fig. 1A). Laboratory results revealed elevated creatinine kinase (CK; 828 U/L) levels, although autoantibody tests, including anti-GAD antibody (0.23 U/mL), rheumatoid factor, antithyroglobulin, and antinuclear antibody levels, were all negative. Electromyography revealed continuous motor unit activity in the agonist and antagonist muscles despite attempts by the patient to relax the muscles (Fig 2). There was no evidence of fibrillation potentials or positive sharp waves on EMG during the silent period. Brain MRI was normal. Limb MRI revealed bilaterally increased signal intensity in the biceps, triceps, rectus femoris, semitendinosus, and biceps femoris muscles (Fig. 3A and B). PET showed increased uptake within the same muscles and did not reveal evidence of malignancy (Fig. 3C). Based on the clinical feature, MRI, PET and electromyography results, SPS was presumptively diagnosed. However, elevated CK level and signal change in the biceps and rectus femoris muscles on MRI were not fully explained by the diagnosis of SPS. Thus, muscle biopsy on the right rectus femoris was performed. Pathology revealed pathologic signs of inflammatory myopathy (Fig. 3D). Since administration of oral diazepam and steroid exhibited no effect, we attempted to administer intravenous immunoglobulin (IVIG). After IVIG therapy, CK levels were normalized, although sometimes it is not fully. Despite serial IVIG treatment, her stiffness, hypertrophy, and limb and axial musculature pain have gradually worsened over the previous four years (Fig. 1B and C). Discussion SPS diagnosis is challenging and requires a high degree of suspicion. SPS is a rare neuroimmunological disorder in which an evidence of PM can be seen. PM characteristics

or pathophysiology in SPS have not been fully explained. We describe a patient diagnosed with SPS associated with PM secondary to sustained muscle contraction.

Fig 1. Inspection of the left arm. (A) The patient’s left biceps and triceps during the first visit. (B)

Hypertrophic change in the biceps and triceps at 1 year after diagnosis. (C) Hypertrophic change aggravated

at 4 years after diagnosis

Fig 2. Electrophysiologic study. (A) Dual channel electromyography recorded with needle electrodes of the

left biceps and triceps. (B) During rest, electromyography revealed continuous motor unit activity

simultaneously in both the biceps and triceps (sensitivity of 200 μV per division and sweep speed of 200 ms

per division)

Fig 3. Results of imaging studies and biopsy. (A) Axial T2-weighted image on left upper arm MRI revealed

signal changes in the biceps as well as the long and lateral head of the triceps (arrows). (B) Axial T2-

weighted fat-suppressed turbo spin echo image on thigh MRI revealed increased signal intensity in the

rectus femoris, semitendinosus, and biceps femoris muscles (arrows). (C) Positron emission tomography

revealed increased uptake in the rectus femoris, semitendinosus, and biceps femoris muscles (arrows). (D)

Biopsy of the right rectus femoris revealed markedly increased fiber size variation (20–100 μm), necrotic

and regenerating fiber, internal nuclei, and inflammatory cell infiltration.

C22

Spinal accessory neuropathy secondary to diffuse large B-cell lymphoma : Case report

Kun-woo Kim1*, Yong-Taek Lee1, Kyung Jae Yoon1, Jung-sang Lee1, Jin-Tae Hwang1, Jong Geol Do1†

Kangbuk Samsung Medical Center, Department of Rehabilitation Medicine 1

Background Spinal accessory neuropathy is a rare disease causing the sternocleidomastoid (SCM) and trapezius muscle palsy, which leads to weakness of contralateral rotation of neck, and scapula winging. Spinal accessory neuropathy caused by tumor is very rare. In this report, we introduce a first case of spinal accessory neuropathy as a result of direct compression by diffuse large B-cell lymphoma. Case report A 49 year old male patient was referred to department of PM&R with a complaint for limitation of motion of right shoulder. He also complained of pain on right upper trapezius area and weakness of left neck rotation, right shoulder forward elevation and abduction. A month ago, He was diagnosed as diffuse large B-cell lymphoma. On physical exam, he had winged scapula, with right scapula laterally translocated, while scapula’s inferior angle was medially rotated. Atrophy of right trapezius and SCM muscle was noted. (Fig. 1). Manual muscle test revealed weakness in left rotation of neck. He could not actively flex his shoulder more than 110 degree, and abduct more than 70 degree. Sensory function test was normal and deep tendon reflex (DTR) showed all 2+ on both upper extremities. To evaluate peripheral nervous system, we conducted nerve conduction study (NCS) and electromyography (EMG). On motor NCS, right SAN showed prolonged terminal latency (3.9ms), and decreased compound motor action potential (CMAP) amplitude (2.9mV), compared with left SAN. Otherwise, motor NCS on bilateral median, ulnar, musculocutaneous and axillary nerve and sensory NCS on bilateral median and ulnar nerve demonstrated no conduction abnormalities. On EMG, examination on right SCM and upper trapezius muscle revealed positive sharp waves in spontaneous activity and reduced recruitment pattern on volitional activity. The other muscles examined showed normal morphology and recruitment pattern and no denervation potentials (Table 1). These findings of electrophysiologic study were compatible with right spinal accessory neuropathy. On ultrasonography (US), right SCM and trapezius muscle showed atrophy compared to contralateral side. (Fig. 2-a,b) On PET-CT scan, cervical lymph nodes that correspond to Level II-V were enlarged and showed high FDG-uptake (Fig. 2-c) The lymphoma was lined up along the pathway that SAN passes by, and it might have directly compressed and damaged SAN. After three cycles of chemotherapy, electrophysiologic study and PET-CT scan were reexamined. On follow-up NCS, CMAP amplitude of SAN was improved from 2.9mV to 5.8mV and terminal latency was shortened, from 3.9ms to 2.3ms, compared with previous study.

Conclusion We described a first case of spinal accessory neuropathy caused by direct compression by diffuse large B-cell lymphoma. Table 1. Motor and sensory nerve conduction studies and needle EMG finding

Fig 1. Right scapula winging. Atrophy of right trapezius and scapula winging is noted

Fig 2. US, PET-CT findings. (A) Short axis view of upper trapezius. Atrophy of right upper trapezius is shown.

The thickness of the muscle was measured as 0.51 cm on the right side and 1.43 cm on the left side. (B)

Short axis view of SCM muscle. Atrophy of right SCM is shown. The thickness of the muscle was measured

as 0.92 cm on the right side and 1.26 cm on the left side. (C) PET-CT findings. High uptake on right cervical

lymph nodes.

C23

Duodenoduodenal intussusception due to a migrated percutaneous radiologic gastrostomy tube in ALS

Ji Won Hong1*, Sang Hun Kim1, Yong Beom Shin1†, Myung Jun Shin1, Eun Gyeom Cha1

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction Malnutrition is a well-known prognostic factor associated with survival in amyotrophic lateral sclerosis (ALS). Hence, nutritional support via percutaneous gastrostomy tube placement in ALS patients is indispensable to prolong survival and improve quality of life. We report an extremely rare but fatal case of duodenal intussusception caused by a migrated percutaneous radiologic gastrostomy (PRG) tube in an ALS. Case Report A 45-year-old woman was diagnosed with ALS in September 2012 at another hospital. Her swallowing difficulty progressed gradually; PRG was performed in August 2015. In November 2015, she first visited our hospital. Swallowing tests were conducted; small amounts of soft/liquid diet could be consumed without aspiration. She performed both tubal feeding and oral diet. Since October 2016, only oral diet was followed and the PRG tube was unused. Tube removal was recommended, but the caregiver refused to visit the hospital due to difficulty in patient transport. Epigastric pain started a month before admission to the emergency department (ED) and aggravated 2 weeks prior with nausea and anorexia. At ED admission, abdominal tenderness was not prominent, but severe epigastric discomfort with abdominal distention and infection signs such as tachycardia (HR 120~130 bpm) and severe leukocytosis (WBC 30.32 10E3/uL) were observed. A computed tomography (CT) scan of the abdomen and pelvis demonstrated abnormal gastric distention due to duodenal intussusception. The PRG tube end had migrated to the second portion of the duodenum (Fig. 1). We decided to remove the PRG tube and reduce intussusception using the air reduction maneuver under radiologic guidance. Although there was some difficulty in removing the tube due to the adhesion, tube removal and air reduction were successfully completed under fluoroscopic guidance by an interventional radiologist (Fig. 2). Five days later, a follow-up CT scan revealed complete tube removal without complications. Subsequently, the patient could feed orally and was discharged 10 days after hospitalization. Discussion Two gastrostomy tube placement types are known: percutaneous endoscopic gastrostomy (PEG) and PRG. Several studies demonstrate that PRG (sedation not required) has a higher success rate and lower complication rate in ALS patients. PEG is usually performed using a tube with a balloon or mushroom catheter tip, but in PRG, a cope loop gastrostomy tube is often used, which does not have a device like that. In our case, intussusception was caused by the non-balloon-type tube. Intussusception can occur regardless of tube type. Migration is the most important cause of intussusception. As in this patient, if the tube is left unused for long, external site management is neglected and

considerable time passes after migration. Gastrostomy tubes should be removed immediately if unused, but if immediate removal is difficult, as in this patient, external site care is vital.

Fig 1. CT abdomen images of duodenal intussusception by the PRG tube

Fig 2. Fluoroscopy-guided gastrostomy tube removal procedure and the tip of the PRG tube

C24

Bilateral facial neuropathy due to vincristine administration

Mi-hyang Han1*, Kee-Boem Park1, Jihye Park 1†

Seoul St. Mary’s Hospital, The Catholic University of Korea, School of Medicine, Seoul, Korea, Department of Rehabilitation Medicine1

Introduction Vincristine binds with tubulin and inhibits microtubule formation in the mitotic spindle at the metaphase stage of cell division and is used in the treatment of lymphoma, leukemia, and small cell lung cancer. Vincristine changes structure in microtubules of peripheral nerve and causes a sensorimotor and autonomic neurotoxicity, and rarely causes cranial neuropathies. We report on a case of vincristine-induced bilateral facial neuropathy in a patient with lymphoma. Case A 35-year-old woman was referred to our department with complaint of bilateral facial palsy that had occurred acutely three months ago in left side and two months ago in right side. She was diagnosed with Diffuse Large B cell lymphoma involving right sacral ala about two years ago. She underwent six cycles of rituximab at 375 mg/m2, cyclophosphamide at 750 mg/m2, doxorubicin at 50 mg/m2, vincristine at 1.4 mg/m2, and oral prednisone 100mg chemotherapy, and radiation therapy. She received maximal dose of vincristine (2mg) for six cycles. In the past history, she visited to oncology department with complaint of diplopia and difficulty of side gazing of right eye. She got brain magnetic resonance image(MRI) and cerebrospinal fluid(CSF) study, and there was no evidence of central nervous system metastasis. Three months later she suddenly complained of right facial palsy. She could not wrinkle her right forehead, close her right eye completely, and smile on the right, and was in House-Brackmann facial(H-B) grade IV. She had no swallowing difficulty, hearing impairment, and visual defect. Having been diagnosed with Bell’s palsy, she received steroid pulse and rehabilitation. Her right facial movements got better and H-B grade improved to grade III. One month later she complained that facial palsy proceeded to the left side. She could not make any movement of left facial muscles, and was in H-B grade V. We conducted nerve conduction studies(NCS), blink reflex examination, and electromyography(EMG) on both side of facial muscles, and the result showed severe axonal degeneration of bilateral facial nerves. To identify the causes of facial palsy, we performed NCS and EMG on all extremities and observed sensorimotor peripheral polyneuropathy with denervational potentials.(Table1,2) She received steroid pulse therapy and rehabilitation again, and two months later the left facial movements improved to H-B grade IV. Conclusion Bilateral facial neuropathy due to vincristine toxicity is rare and there was only one case report that did not perform electromyography. We determined vincristine to be the cause of bilateral facial palsy when considering the onset of symptoms. Additionally, we confirmed the axonal injuries of bilateral facial nerves by electromyography. In case of

high-dose vincristine usage, patients should be carefully monitored for unexpected neurologic toxicity. Furthermore, cranial neuropathy induced by vincristine should be well differentiated from brain metastasis. Table 1. Result Of The Nerve Conduction Studies

Table 2. Result Of The Needle Electromyography

C25

Abdominal Wall Pseudohernia due to Herpes Zoster : Case-report

Ha Ra Jeon1†, Hyeon Su Kim2*, Seong Woo Kim1, Da Wa Jung1, Jun Min Cha1

National Health Insurance Service Ilsan Hospital, Department of Physical Medicine and Rehabilitation1, Severance Hospital, Department of Rehabilitation Medicine2

Introduction Herpes zoster is a clinical syndrome caused by reactivation of a varicella-zoster virus (VZV) and it is characterized by the cutaneous distribution of rash and vesicles in the affected dermatomes. Sensory symptoms such as neuropathic pain and hypoesthesia are often accompanied in the affected dermatomes. Motor segmental paralysis is not common complication, but it can also occur in about 0.5% to 5.0% of patients with herpes zoster. Low-thoracic levels paresis in herpes zoster causes abdominal muscle weakness, which can lead to the abdominal wall protrusions or pseudoherniation. There has been few reports on herpes zoster induced abdominal pseudohernia. Here we present a case of abdominal wall pseudohernia caused by thoracic herpes zoster and neurophysiologic findings. Case A 62-year-old man visited the Physical Medicine and Rehabilitation outpatient clinic with complaint of right abdominal wall protrusion. Four weeks prior to visit the Physical Medicine and Rehabilitation clinic, he visited department of Family Medicine with complaint of characteristic herpetic rash and hyperesthesia at T10-12 dermatomes on right side. He diagnosed with herpetic zoster and took priscribed medicine. One week after the onset of the rash and pain, he noticed an abdominal wall protrusion in the area of the herpetic rash. Abdominal ultrasound, spine magnetic resonance imaging (MRI), needle electromyography (EMG) test, and dermatomal somatosensory evoked potential (SEP) were performed. There were no abnormal findings in abdominal ultrasound and MRI. In EMG studies, there were abnormal spontaneous activities in the right paraspinal muscles of T10-T12 levels, rectus abdominis and external oblique muscles. Dermatomal SEP studies showed prolonged latency of right T10 and T12 dermatomes. Conclusion Segmental motor weakness presenting with abdominal wall pseudohernia is a rare complication of herpes zoster. It is important to recognize such complication to avoid unnesseccary procedure or surgery because it is reversible and has good prognosis. Electromyography and dermatomal SEP are useful tool to evaluate clinical status and localize neurogenic lesion.

C26

A CASE OF TRUE NEUROGENIC THORACIC OULET SYNDROME ACCOMPANIED BY AN ELONGATED C7 TRANSVERSE PROCESS

Hong Beom Park1*, Ki Hoon Kim1, Baek Hyun Kim1, Dong Hwee Kim1†

Korea University College of Medicine, Department of Physical Medicine & Rehabilitation1, Korea University College of Medicine, Department of Radiology2

Objective and Background True neurogenic thoracic outlet syndrome (TOS) is an unusual disease and hard to diagnose. Enlarged C7 transverse process is one of leading causes of TOS. We present a case of true neurogenic TOS correlated with enlarged C7 transverse process which was diagnosed by radiologic studies including magnetic resonance images (MRI) and computed tomography (CT). Case presentation A 61-year-old man complained of progressive tingling sensation on the right medial forearm, and 4th and 5th fingers with shoulder pain for 4 years. On physical examination, sensation to touch was decreased in the right medial forearm and 4th and 5th finger. Muscle strength (Medical Research Council grade) of the right upper extremity demonstrated that abductor pollicis brevis (APB), abductor digiti minimi (ADM) and first dorsal interosseous (FDI) muscles were grade 3, but elbow flexor, wrist and finger extensor, grade 5. Compound muscle action potential (CMAP) of the right median nerve was decreased. Sensory nerve action potential (SNAP) of the right medial antebrachial cutaneous nerve was not evoked, and SNAPs of the right ulnar sensory nerve, dorsal ulnar cutaneous nerve, and median sensory nerve with third digit were decreased. But the right median sensory response with the first digit recording was normal. On needle electromyographic examination, abnormal spontaneous activities and/or large amplitude and long duration motor unit action potentials with reduced recruitment patterns were demonstrated the median and ulnar-innervated muscles originated from medial cord of the right brachial plexus. MRI of the right brachial plexus showed that the distal portion of lower trunk was compressed between subclavian artery and tip of transverse process (FIGURE A). CT demonstrated that enlarged and downward C7 transverse process and subclavian artery narrows outlet of lower trunk (FIGURE B). Plain X-ray of cervical spine showed bilateral elongated C7 transverse process, especially more elongated and downward transverse process on the right side. He refused surgical treatment. Conservative treatment including steroid therapy for 2 months, symptoms were relieved. Conclusion The enlarged, downward transverse process is a rare cause of true neurogenic TOS and should be considered in the differential diagnosis in a patient with a suspected TOS.

Fig A. MRI of the right brachial plexus showed compression of the distal portion of lower trunk between

subclavian artery and C7 transverse process tip: thin arrow, subclavian artery; thick arrow, lower trunk;

asterisk, tip of elongated C7 transverse process.

Fig. B. CT showed that the lower trunk of right brachial plexus was compressed between the subclavian

artery and the tip of C7 transverse process (T) (a) as compared to the left side (b): A, subclavian artery; T, tip

of elongated transverse process.

C27

Abrupt onset hoarseness with left recurrent laryngeal neuropathy caused by aortic arch aneurysm

Sang Ho Oh1*, Junmo Cho1, Si Hyun Kang1, Don-Kyu Kim1, Kyung Mook Seo1, Jaewon Beom1†

Chung-Ang University Hospital, Chung-Ang University College of Medicine, Department of Physical Medicine and Rehabilitation1

Background Ortner's syndrome, also known as cardiovocal syndrome, refers to vocal cord paralysis caused by compression of the left recurrent laryngeal nerve by cardiovascular disorders such as thoracic aortic aneurysm. Among the previous case reports, one patient suffered an aortic aneurysm rupture one month after the advent of hoarseness, necessitating emergency surgery with aortic arch replacement. Other patients underwent elective aortic arch replacement surgery. In this report, we describe the case of Ortner's syndrome confirmed by laryngeal electromyography, and suggest feasible rehabilitation strategy. Case Presentation An 88-year-old female was hospitalized for rehabilitation after an open reduction and internal fixation surgery due to the intertrochanteric fracture of right femur at another hospital. She had medical history of hypertension, tuberculosis, pneumothorax, and osteoporosis. No other significant cardiopulmonary symptoms or dysphagia were found. Four weeks after operation with spinal anesthesia, the patient complained of hoarseness of voice which has not much improved. Laryngoscopy revealed vocal cord asymmetry, and was negative for mass lesion (Figure 1). Ultrasonography also showed decreased movement of left vocal cord. Because spinal anesthesia was carried out, intubation-induced vocal cord palsy could be ruled out. A contrast-enhanced computed tomography (CT) scan of the neck and chest showed a 6.5 cm-sized saccular aneurysm with mural thrombi in the aortic arch (Figure 2). Laryngeal electromyography revealed abundant positive sharp waves and fibrillation potentials with reduced recruitment at the left thyroarytenoid muscle (Figure 3), which was consistent with partial axonal loss of the left recurrent laryngeal nerve. There was no abnormality at the left cricothyroid muscle. We determined to observe the progression after consulting the cardiology and cardiac surgery departments because there was no change in aneurysm size when compared with follow-up CT in 4 weeks. After about 40 days of rehabilitation, there was improvement in lower extremity motor power, functional ambulation and balance, and hoarseness was slightly improved. Conclusion When the patient presents with hoarseness, we should be aware of the possibility of cardiovascular causes to avoid delays in diagnosis. If there is no need for immediate operative intervention and hoarseness are improving, rehabilitation such as gait and

balance training can be safely conducted. In addition, short-term CT follow-up may be needed to evaluate the size change of the aortic aneurysm.

Fig 1. Laryngoscopy that revealed vocal cord asymmetry and was negative for mass lesion.

Fig 2. A contrast-enhanced CT scan that showed a 6.5 cm-sized saccular aneurysm with mural thrombi in the

aortic arch.

Fig 3. Laryngeal electromyography which revealed positive sharp waves and fibrillation potentials (A) with

reduced recruitment (B) at the left thyroarytenoid muscle.

C28

A Lumbosacral Plexopathy, Compressed by Huge Uterine Myoma

Seong Hoon Lim1*†, Sung Jong Lee1, Bo Young Hong1, Joon Sung Kim1, Won Jin Sung1, Joo Hee Yoon1

St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Department of Rehabilitation Medicine1, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Department of Obstetrics and Gynecology2

A 54-year old female visited a rehabilitation outpatient clinic with a 2-week history of right-sided foot drop and pain on the dorsum of the right foot. The patient had undergone total right knee arthroplasty 2 weeks prior to presentation. Electrodiagnostic studies were conducted to test for peroneal or sciatic nerve injury secondary to the surgical intervention. The left sural nerve was obtained normally. No discernable response followed superficial peroneal nerve stimulation from the lateral calf. Reduced amplitude of the compound muscle action potential (CMAP) was observed at the tibialis anterior muscle on common peroneal nerve stimulation (Table 1). Needle electromyography of the right lower limb revealed abnormal spontaneous activities, such as positive sharp waves and fibrillation potentials, of the long and short heads of biceps femoris, tibialis anterior, fibularis longus, and tibialis posterior muscles at rest. The interferential patterns were reduced at all denervated muscles on maximal volition. Together, these findings were suggestive of right proximal sciatic nerve injury or lumbosacral plexopathy. Magnetic resonance imaging (MRI) (3.0T MRI, Siemens, Germany) of the lumbar spine and pelvis revealed that multiple, variable-sized, intramural and subserosal myomas had nearly replaced the uterus. The largest myoma was in the anterior mid- to lower body of the uterus and measured 11.8 x 11.6 x 11.5 cm. Another large myoma was located near the right L5 root outlet and the right lumbosacral plexus (Figure 1). The patient was referred to the Department of Obstetrics and Gynecology for a total hysterectomy (Figure 2). Post-operatively, the patient had recovered right lower-limb strength. Follow-up electrodiagnostic studies showed marked improvement of the interferential pattern during maximal voluntary muscle contraction. Lumbosacral plexopathy typically occurs following trauma. Uterine myomas are a rare cause, and have only occasionally been previously described1. In this case, a prolonged supine position during anesthesia for knee surgery likely caused a compression of lumbosacral plexus by a uterine myoma. In the physiatrist’s view, the discrepancies between the clinical history and the electrodiagnostic evidence were crucial for informing diagnosis and treatment planning.

Fig 1. T2 sagittal and axial magnetic resonance imaging (MRI) showed multiple, variable-sized, intramural

and subserosal myomas had nearly replaced the uterus. A uterine myoma was located near to the right L5

root outlet and right lumbosacral plexus.

Fig 2. Surgical exploration revealed huge myoma

Table 1. Findings of the initial nerve conduction study

C29

Successful IVIG treatment without Discontinuation of TNF α blocker in GBS Induced by Adalimumab

Ju Young Cho1*, Dae Hee Lee1, Kwang Jae Yu1, Hyunseok Moon1, Zeeihn Lee1, Jong-Min Kim1, Donghwi Park1†

Daegu Fatima Hospital, Department of Rehabilitation Medicine1

Introduction Adalimumab, one of the anti-tumor necrosis factor (TNF) α blockers, is known to be associated with the development of Guillain-Barre syndrome (GBS). Although not clearly decided so far, discontinuation of adalimumab is recommended when GBS occurs during adalimumab treatment. Until now, however, there has been no report that showed improvement of GBS after intravenous immunoglobulin (IVIG) treatment without discontinuation of adalimumab. Case A 33-year-old woman who had suffered from Crohn’s disease (CD) for 14 years complained of weakness of both the upper and lower extremities after the fourth injection of adalimumab. Before GBS occurred, her gastrointestinal symptoms of CD were well controlled through adalimumab treatment, unlike other treatments that had caused unbearable side effects. After obtaining informed consent, she began to receive treatment for GBS with IVIG, but without adalimumab discontinuation because she wanted to continue the adalimumab treatment. In spite of treatment continuing using adalimumab, she recovered considerably from her neurologic abnormality, which remained tolerable for one year without recurrence of GBS. Discussion The association between adalimumab and GBS needs to be elucidated, but one of the hypotheses is that adalimumab can trigger the syndrome by promoting its autoimmune reactions by alteration of the antigen-presenting cell function and reduction of autoreactive T-cell apoptosis through the blocking of TNF-α. In addition, TNF-α blocking therapy can interfere with the intrinsic immunity given by TNF- α and other cytokines in the peripheral nervous system, arousing the syndrome in immune-genetically highly susceptible individuals. Despite the broad efficacy of IVIG therapy on GBS, the mechanism of IVIG on GBS has not been clearly elucidated. Recently, however, it was demonstrated that IVIG induces the amelioration of antibody-dependent autoimmune processes by several steps. First, IVIG therapy induces immunomodulatory effects by resetting the threshold for innate immune effector cell activation. The up-regulation of the inhibitory receptor Fcγ (FcγRIIB) on human B cells induced by IVIG may increase their sensitivity to apoptosis and thus may have a direct impact on auto-antibody production. Secondly, IVIG inhibits the toll-like receptors (TLR) 9 and TLR 7, mediates B cell activation and suppresses TLR-induced production of pro-inflammatory cytokine, which causes up-regulating T-cell-dependent inflammation. Considering these aspects, IVIG may have an immediate impact on autoantibody-induced inflammation. Although the mechanism of GBS is not clear,

continuous treatment with adalimumab did not trigger GBS in the patient in our study after recovering almost completely from the disease. We hypothesize that a transient production of auto-antibodies which cause GBS may be ameliorated by immunomodulatory actions of IVIG therapy.

C30

Herpes Zoster induced Brachial Plexopathy Affecting whole branches: a case report

Tae Jun Min1*, Si Hyun Kang1†, Don-Kyu Kim1, Kyung Mook Seo1, Jaewon Beom1

Chung-Ang University Hospital, Department of Rehabilitation Medicine1

Background Herpes zoster is an infectious disease characterized by vesicobullous skin eruptions in a dermatomal distribution and neurological complication. The most common neurologic complication of herpes zoster is chronic pain, and motor paralysis is a less common complication. Until now, a few cases have been reported about motor paralysis as brachial plexopathy (BPI) after herpes zoster infection. Most of these cases showed BPI involving one or two segments, and in this case report we report a patient with brachial plexopathy involving whole branch confirmed by needle electromyography. Case A 88 year old female patient visited the hospital with bullous skin lesion in neck, right whole arm. She complained tingling sense, pain, and swelling on the involved area. Under diagnosis of Herpes zoster, she took the anti-viral agents, and 3 days later, the bullous skin lesion in hands is proceeded to the proximal part of body. She was admitted in the neurology department and her symptoms were improved with proper medication and two months later, pain was much improved and the skin lesion was changed to chronic scar (Fig. 1) However, she was referred for electrodiagnostic study through the orthopedics because she reported that weakness on this right upper extremity had started. On physical examination, muscle power on elbow flexion was grade 4, elbow extension was grade 4, wrist extension was grade 4, finger flexion was grade 3, finger abduction was grade 3, finger extension was grade 3. She showed difficulties in fine motor control and during performing fine motor task she showed mild tremor. She also had tingling sensation and hypothesia on this whole arm. To evaluate this delayed weakness, we performed electrodiagnostic study [Table 1] [Table 2]. In motor nerve conduction study, conduction velocity of median, ulnar and radial nerve was decreased. Amplitude of sensory responses was decreased in median, ulnar, superficial radial, lateral antebrachial cutaneous, and medial antebrachial cutaneous nerve. Needle electromyography showed abnormal spontaneous activities in the muscles innovated from axillary, musculocutaneous, median, ulnar, radial nerves. Synthesizing the clinical symptoms, physical examination and eletromyography, she was diagnosed as the brachial plexopathy, whole branch involved, after herpes zoster infection. We performed magnetic resonance imaging (MRI) study, and it showed diffuse swelling of entire right brachial plexus. The patient was enrolled to the occupational therapy and continued medication (steroid). After one month of rehabilitation, weakness and sensory symptoms were much improved.

Conclusion Severe herpes zoster infection could cause not only skin lesion/sensory symptom but also motor weakness. Whole branch involving BPI after herpes zoster infection is a rare case, and electrodiagnostic study is helpful for accurate diagnosis. Proper rehabilitation program would be needed also to improve the motor weakness.

Fig. 1. Bullous skin lesion of right upper extremity in 88 year old female

Table 1. Nerve conduction study

Table 2. Needle Electromyography

C31

Neurophysiological Effect of Intravenous Corticosteroid during Spinal Cord Tumor Removal

Jinyoung Park1*, Dawoon Kim2, Junseok Oh2, Jihyun Park2, Yong-Eun Cho1, Yoon Ghil Park1†

Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Rehabilitation Medicine1, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Rehabilitation Medicine2, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, Department of Neurosurgery3

Objective There have been controversies over the effects of the high dose IV corticosteroid for acute spinal cord injury. A few studies tried to reveal the effect of IV prednisolone on electrophysiological outcomes, and there is no report on direct (D) waves, somatosensory evoked potentials (SEPs) or motor evoked potentials (MEPs). Thus we report a case of which revealed the intraoperative neurophysiological effect of IV corticosteroid during surgery. Methods 1) Patient A 72kg, 58-year-old man visited the Department of Neurosurgery complaining numbness and weakness in 2004. By the magnetic resonance imaging (MRI), cavernous malformation was revealed at T3/4 level. Despite the progressing weakness and sensory deterioration of bilateral lower extremities, he has been refused surgery until the additional urinary and fecal incontinences developed. After confirming hemorrhage in tumor by MRI (Figure 1A and 1B), and he finally agreed for surgery in 2018. The motor score of bilateral 10 key muscles was 94. 2) Anesthesia Total intravenous anesthesia was continued with remifentanil and propofol. 3) Intraoperative Neurophysiological Monitoring The MEPs were obtained by delivering the short trains of 6 square-wave stimuli (duration 0.5 ms, inter-stimulus interval 3 ms) with supra maximal intensity (250V~400V) at C1 and C2 scalp sites, and recording in bilateral deltoids, abductor pollicis brevis, tibialis anterior (TA), and abductor halluces (AH). The SEPs were elicited by stimulating bilateral posterior tibial nerves at the ankles (duration 0.2 ms, repetition rate of 5 Hz), and recording at C3, C4 and Cz referenced to FPz. D waves was obtained stimulating the same sites as MEPs with single pulse (duration 0.5 ms, intensity 150~200 mA), and recording on epidural space of T2 and T5 levels. Results During tumor removal, the sequential P37 latencies of bilateral posterior tibial nerves showed no significant changes. However, the MEPs dropped to 11.3% of the baseline amplitude in right TA and AH (Figure 2). After promptly alarmed to neurosurgeon, and the IV SOLU-MEDROL® (methylprednisolone sodium succinate) was administered with 30 mg/kg during 15 min and again with a rate of 5.4 mg/kg/hr during next 23 hours. While

the final MEPs stayed 11.2% and 15.3% of the baseline amplitude in right TA and AH, the amplitude of the D wave in T2 and T5 abruptly amplified to 597% and 563% within 3 minutes after administration compared to the amplitude just before corticosteroid administration (Figure 3A), and ended with 657% and 504% of the baseline before dura closing (Figure 3B). A day after surgery, the MRI revealed small amount of hemorrhagic residue (Figure 1C and 1D), and the motor score improved to 95 from 94 Conclusion Prompt administration IV corticosteroid would prevent motor deterioration even with compromised MEPs over alarm criteria, and the amplification of the D wave right after steroid administration may be a signal to good prognosis.

Fig 1. Preoperative and postoperative magnetic resonance images of the intramedullary cavernous

malformation.

Fig 2. Significant reduction in amplitudes of motor evoked potentials during tumor removal.

Fig 3. Direct waves amplified after administration of intravenous methylprednisolone.

C32

Hirayama Disease with Proximal Upper Extremity Atrophy mimicking Brachial Plexopathy : A Case Report

Chang Beom Kim1*, Chan Hyuk Park1, Hyun Sung Lee1, Kyung Lim Joa1, Chang Hwan Kim1, Han Young Jung1, Myeong Ok Kim1†

Inha University School of Medicine, Department of Physical & Rehabilitation Medicine1

Introduction Hirayama disease is characterized by progressive muscular weakness and wasting of unilateral forearms and hands in young people. The hypothesis is based on chronic ischemic damage to the lower cervical cord caused by crushing against the vertebral bodies, during neck flexion movements. The patient of this case was army, and he complained insidious onset of weakness and atrophy in the upper arm. Because he occurred these symptoms following hard military work, we initially suspected the possibility of traumatic brachial plexopathy. Through electrodiagnostic study, brachial plexus, cervical spine MRI, we reported this rare case of Hirayama disease with bilateral and proximal arm muscle involvement. Case Report A 20-year-old military man visited our outpatient clinic with eight months history of slowly progressive atrophy that started in the right proximal upper extremity following heavy military training (Fig. 1). Physical examination revealed wasting and weakness of triceps brachii, extensor digitorum muscles but no evidence of sensory change. With initial impression of traumatic brachial plexopathy following heavy training, we studied brachial plexus MRI and electrodiagnostic study. To rule out the possibility of Guillain Barre syndrome, the CSF study and serum anti GM1 antibody study have done, the result was normal. Brachial Plexus MRI revealed no definite abnormal finding. Upper limb MRI revealed decreased volume and increased signal intensity at triceps, extensor digitorum, exstensor digiti minimi, extensor carpi ulnaris muscles, suggesting denervation change. Nerve conduction study revealed delayed F wave latency of both median and ulnar nerve. In a needle EMG, denervation potentials and polyphasic motor unit action potentials were observed in the bilateral triceps brachii, flexor carpi radialis, extensor digitorum communis, abductor pollicis brevis, and abductor digit quinti muscles. The above findings revealed segmental anterior horn cell disease (Table 1). We performed cervical spine MRI to assess the relationship of posterior dura mater with the spinal cord through extention and flexion of the neck. During neck flexion, the posterior dura showed anterior displacement. An associated anterior displacement and mild flattening of spinal cord from C5-6 to C6-7 level but no abnormal intramedullary high signal intensity were found (Fig. 2). So, we diagnosed his case as Hirayama disease involving bilateral upper extremities through electrodiagnostic and cervical MRI findings. We recommended upper extremity muscle strenghthening, and avoidance of neck flexion.

Conclusion We experienced a rare case of the bilateral and proximal weakness of upper extremity in Hirayama disease. Because this case is quite different from other ones, we report it. Although the pathogenesis is not clear, early recognition of this condition is important because avoidance of neck flexion can retard the progression of Hirayama disease.

Fig. 1. Findings of muscular atrophy of the right arm. (a) triceps brachii muscle, (b) extensor digitorum

muscle

Table 1. Nerve Conduction Study and Needle Electromyographic Findings of Both Upper Extremities in This

Case.*: Abnormal data MC: musculocutaneous nerve, LABCN: lateral antebrachial cutaneous nerve, CV:

conduction velocity, Amplitude (mV) in motor conduction study, Amplitude (uV) in sensory conduction

study Spont. activity: spontaneous activity, MUPs: motor unit potentials, Fibs: fibrillation potentials, PSW:

positive sharp waves, Poly: polyphasia, Amp: amplitude, Dur: duration, R: reduced recruitment, F: full

recruitment

Fig. 2. Cervical spinal cord MRI in neck flexion position showed minimal posterior dural detachment at C4, 5,

6 levels. (a) extension position on T2-weighted image, (b) flexion position on T2-weighted image, (c) Axial

T2-weighted image shows mild flattening of spinal cord from C6-7 level on flexion position

C33

A successful therapy of neuralgic amyotrophy with local steroid injection and low dose oral steroid

Lee Hyun Sung1*, Kim Chang Hwan1†

Inha University Hospital, Department of Rehabilitation Medicine1

Back ground The pathophysiology of idiopathic neuralgic amyotrophy (INA) has been presumed to be localized inflammatory immune process in brachial plexus. Persistent pain and weakness remain in about 20% of INA patients without treatment. Up to now, high dose oral corticosteroid therapy is conventionally used for the treatment of INA. This would help control systemic inflammation, but about 20% of patients has experienced systemic side effects. Therefore, we intended to modulate therapeutic approach to be locally active by performing ultrasound-guided brachial plexus and cervical root block with reduced the dose of steroid. The purpose of this therapy is to improve functional recovery with effective pain control and reduce systemic side effects of steroid. Case One month ago, a 41-year old right handed female has got common cold and this has gradually got better. Two weeks later, she felt acute pain and sudden weakness on left upper arm without trauma and sensory loss. Her history was negative for hereditary or metabolic neuropathies. On physical examination, she had proximal muscle weakness of left upper limb without atrophy; shoulder flexion and abduction (MRC score 2/5), elbow flexion (MRC 4/5). A laboratory study showed no evidence of abnormalities. We performed nerve conduction study and needle electromyography at 2 weeks after onset, suggesting of C5 radiculopathy. However, we suspected brachial plexus lesion regarding her history and physical examination clinically. We have finally diagnosed an INA by brachial plexus MRI, it showed the brachial plexopathy involving divisions and lateral, posterior cord with mild swelling on C5 nerve root, suggesting C5 radiculopathy (Fig. 1). We started low dose oral steroid therapy (0.5 mg/kg for 3 days, 0.4mg/kg for 3 days, 0.2mg/kg for maintaining dose, totally 4 weeks course) about 2 weeks after onset. Concurrently, 2 weeks interval, 3 times ultrasound-guided brachial plexus injection (dexamethasone 5mg, 2 times on C5 root and triamcinolone 40mg, 1 time on division level of brachial plexus) were performed (Fig. 2). We used MRC grades of the following 3 muscle pairs comprising the MRC sum score; shoulder flexor, abductor and elbow flexor. These muscles grade in MRC sum score (total score:15) were increased from 8 to 13 in one month, and further improved up to 15 in 2nd months. The pain scale (NRS) was graded from 5 to 2 and finally 0 in the same periods. Conclusion Although the precise pathophysiology of INA is unknown, it is thought to be associated with localized inflammatory-immune attack. In comparison with previous studies, this case report showed ultrasound-guided steroid injection with low dose steroid therapy could induce successful functional recovery and effective pain control without the

systemic complications of steroid. Therefore, localized ultrasound-guided brachial plexus injection would be a recommendable approach to treat INA.

Fig 1. a Sagittal T2 water excited image shows mild high signal intensity at left supraspinatous,

infraspinatous muscle, suggesting denervation change related to suprascapular nerve b Axial T2 image

shows left C5 nerve root compression with mild swelling(red arrow) c Coronal T2 water excited image shows

swelling and high signal intensity left divisions and lateral, posterior cord(red arrows)

Fig 2. Ultrasound guided injection on left brachial plexus at the level of division (short arrow); Needle path

(long arrow)

C34

Management of Uncontrolled Orthostatic Hypotension with Diabetic Autonomic Neuropathy

Seung Hee Han1,1*, Ga Yang Shim1,1, Jong Kyu KIM1,1†

Seoul Medical Center, Department of Physical Medicine and Rehabilitation1

Introduction Diabetic polyneuropathy is one of the most problematic complications in patients with diabetes mellitus. In autonomic neuropathy, they suffered from various symptoms including dizziness, dyspepsia, urinary incontinence, etc. We experienced a rehabilitation case of diabetic autonomic neuropathy with uncontrolled orthostatic hypotension and report it. Case A 47-year-old man admitted for weakness in all 4 extremities. He was diagnosed diabetes, but he stopped medication against doctor’s recommendation for 5 years. One year ago, he slept down and got a temporal bone fracture, and aggravated to pterygomandibular abscess. After surgical treatment, he became quadriplegic and refused any treatment. He has lived for 6 months at home without any medicine and any rehabilitation with a bed-ridden state. At administration, upper and lower limb muscle strength was measured at 3/5 grade.(Table 1) His sensation of all 4 extremities was decreased. His HbA1c was measured as 16.4%. The electrodiagnostic study showed peripheral polyneuropathy with autonomic neuropathy.(Table 2) He could not maintain sitting position more than 5 minutes because of symptomatic orthostatic hypotension. We started diabetes medication. We applied elastic compression stocking and abdominal binder for severe orthostatic hypotension. But even at 40 degrees on the sloping bed, he could not tolerate only 5 to 10 minutes, and he could not use a wheelchair. At the 7th day of hospitalization, Fludrocortisone 0.1mg was administered, and at the 14th-day midodrine 2.5mg was administered. However, he complained of dysuria, so midodrine was discontinued 4 days later. He showed poor response to these medications. We applied exercise therapy including motorized bicycle (Superdynamics), his symptoms were getting better. After 20 days of exercise, he could use a reclining wheelchair for ambulation. Finally, he was able to walk on a parallel bar with assistance and use a regular wheelchair in ordinary times.(Table 3) Conclusion We experienced a rehabilitation for severe orthostatic hypotension in a diabetic autonomic neuropathy patient. Comprehensive approach including pharmacologic, non-pharmacologic treatment, and rehabilitation exercise were applied. In our experience, the most effective modality was lower extremity exercise using a motorized stationery bicycle. It gave symptom relief and daily living improvement. In the future, larger sized study with comprehensive rehabilitation program would be required.

Table 1. Results of Manual Muscle Test

Table 2. Summary of Electrodiagnostic Test

Table 3. Summary of Orthostatic Hypotension Management

C35

Peroneal nerve palsy due to intraneural ganglion cyst

Da Hwi Jung1*, Ra Yu Yun1, Yong Beom Shin1, Jae Hyeok Chang1, Myung Jun Shin1, Byeong-Ju Lee1†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction Foot drop is common symptoms that a physiatrist could meet at electrodiagnostic lab. To confirm the affected region, electromyogram (EMG) is significant and useful. The lesion would be exist from the anterior horn cell at the lumbar spinal cord through lumbosacral plexus to peroneal nerve. The peroneal nerve palsy could be caused by traumata or occur insidiously by mass lesion or metabolic syndromes. In this case, peroneal nerve palsy at or around fibular head was diagnosed by EMG at emergency room. The physition could intervene early which is fundamental to prevent permanant gait abnormality. Case Report 60-year-old woman visited the emergency room on July 7th, 2017. She complained of the right foot drop 3 days ago. She had medical history of diabetes mellitus and Graves’ disease and had both total knee replacement 5 years ago. There was no history of trauma. The primary physition and the neurosurgeon suspected lumbar radiculopathy, so ordered the magnetic resonance imaging of lower back. There was no evidence of disc herniation or root compression. Therefore she was referred to the deparment of rehabilitation medicine for an EMG test. On the manual muscle test (MMT) , the right ankle dorsiflexion was T, ankle eversion was P, great toe extension was T and 2nd to 5th toes were T grade. There was a palpable mass around the right fibular head and Tinnel sign was positive. On EMG, compound muscle action potentials (CMAPs) of the deep peroneal nerve stimulated at the ankle and around the fibular head were normal. However, the CMAP stimulated at the popliteal fossa showed decreased amplitude. Findings were compatible with the conduction block of right peroneal nerve (Fig 1). On ultrasonography, the cystic mass was observed around the right fibular head (Fig 2). Excision of the cyst was delayed to 10 days after the diagnosis, July 24th, 2017, due to the risk of thyrotoxicosis and poor control of blood glucose level. In the operation field, bulging cyst was found on the fascia and the cystic mass inside the nerve sheath along the common peroneal nerve. After dissecting the cyst from the nerve, the atrophy of the nerve was not seen. On the follow-up EMG was done on July 24th and August 10th 2017 showed improvement of interference of motor units of the tibialis anterior muscle (Fig 2, 3). The MMT of ankle dorsiflexion improved as F grade compared with T grade at first. Discussion Since the ganglion cyst in the lower extremity is very rare, the diagnosis of the ganglion cyst around the fibular head in this case would have been very difficult. However, proper history taking, physical examination and the EMG made the diagnosis exactly. It made possible the early intervention to relieve the symptom and the patient was able to

recover motor weakness. This case demonstrated usefulness of the EMG in the emergent situation such as sudden motor weakness.

Fig 1. Nerve conduction test findins at first

Fig 2. Needle electromyographic findings

Fig 3. Nerve conduction test findings after surgery

C36

Sensory neuronopathy with ataxic gait and fine motor difficulties: A case report

Tae Jun Min1*, Si Hyun Kang1†, Don-Kyu Kim1, Kyung Mook Seo1, Jaewon Beom1, Suk Won Ahn2

Chung-Ang University Hospital, Department of Rehabilitation Medicine1, Chung-Ang University Hospital, Department of Neurology2

Background Sensory neuronopathy is known to be occurred by various causes including genetic disease, paraneoplastic syndrome, HIV infection, Sjogren’s syndrome, intoxication, vitamin E deficiency, and even idiopathic origin. We report a patient of idiopathic sensory neuronopathy with ataxic gait and fine motor difficulty relapsing for five years. Case A 73 year old male patient with waxing & waning ataxic gait for 5 years was admitted in Neurology. In nerve conduction study, motor conduction study showed normal results in his four extremities, while the sensory nerves were not provoked in all extremities. After taking steroid and mycophenolate, his symptom was improved and he was discharged. Nine months later, he was admitted again with relapsing ataxic gait and fine motor difficulties. His clinical diagnosis was chronic inflammatory demyelinating polyneuropathy (CIDP) and they performed several laboratory studies and computed tomography (CT), which were all not remarkable. After immunoglobulin therapy, he was transferred to rehabilitation medicine department for proper evaluation and rehabilitation. We evaluated his muscle power and it showed grade 4 in all extremities. Berg Balance Scale score was 23/56. His gait was ataxic, which showed sway during ambulation and wide-based to keep his balance. He had difficulties in fine motor control. In the monofilament test, it showed decreased sensory protective function in the bilateral median, ulnar, and radial sensory area. He showed decreased vibration sense and position sense. We repeated motor and sensory nerve conduction studies and it showed same results with those of previous study.(Table 1, 2) We performed needle electromyography study to know the existence of axonal involvement in motor nerves, and there was no spontaneous activities and all muscles tested showed normal voluntary motor unit action potential. We concluded that his ataxic gait and fine motor difficulties were from sensory neuronopathy/ganglionopathy rather than CIDP. His ataxic gait was improved, his fine motor function was significantly improved, and he could use his chopsticks after 3 weeks of rehabilitation. Conclusion Sensory neuronopathy/ganglionopathy, a subset of peripheral neuropathy, is thought to be related with the degeneration of dorsal root ganglion (DRG). It is usually diagnosed as ‘sensory ataxia’ in neurology clinic, and the patient shows ataxic gait, proprioceptive sensory loss, decreased muscle reflex, and difficulties in fine motor controll. In nerve conduction studies, motor conduction study shows normal or reveals only mild

abnormalities and SNAPs are absent. We confirmed the patient’s diagnosis with the motor and sensory nerve conduction study. The limitation of this study is that we could not perform MRI study of spinal cord to know the involvement of ganglion. Proper rehabilitation including occupational therapy helped the patient restoring the gait and fine motor function. Table 1. Nerve conduction study

Table 2. Needle Electromyography

C37

Suspected neuralgic amyotrophy coexisted with peripheral polyneuropathy mimicking septic arthritis

Mi Kyung Cho1*, Ho Eun Park1, Yong Beom Shin1, Jae Hyeok Chang1, Myung Jun Shin1, Byeong-Ju Lee1†

Pusan National University Hospital, Department of Rehabilitation Medicine1

Introduction Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome is a peripheral nervous system disorder with core features; episodes of extreme pain at symptom onset, rapid multifocal paresis and atrophy of the affected muscles, and slow recovery requiring months to years. NA would be diagnosed clinically first and needs to exclude other cause of plexopathy or neurological conditions. We experienced a meaningful case and would report. Case report A 42-year-old woman visited an emergency room with right shoulder pain and weakness for 3 weeks. The character of pain was stabbing and visual analogue score (VAS) was 8. She complained of chill and decreased mentality for several days before. She had received hemodialysis for end stage renal disease (ESRD). She was diagnosed as type 1 diabetes mellitus (T1DM) and prescribed insulin. Laboratory test showed WBC 5870/uL, segment neutrophil 72.0% and CRP 3.11mg/dL. A magnetic resonance imaging showed focal effusion with enhancement at right glenohumeral joint, subacromial subdeltoid bursa and right biceps tendon sheath. The orthopedic surgeon performed an arthroscopic incision and drainage, but operative finding was clear. Also, systemic inflammation and fever were continued. Finally, she was diagnosed as infective endocarditis and had aortic valve replacement surgery. She was referred to department of rehabilitation medicine for cardiac rehabilitation but she still complained of right shoulder weakness. On physical examination, muscle strength was as follow: right shoulder abduction P- grade, shoulder flexion P grade, elbow flexion & extension F grade, wrist flexion & extension G grade. On electrodiagnostic (EMG) test, there was diffuse motor and sensory peripheral polyneuropathy which showed mixed severe axonal injury and demyelinating pattern. The needle EMG of right shoulder muscles implied mixed myopathic and axonal degenerative pattern. These findings were also showed on the opposite side. Therefore, electrodiagnostic confirm was not decisive (table 1, 2 and fig 1). She was prescribed NSAIDs for pain control and applied physiotherapy of electrical stimulation and strengthening exercise for shoulder weakness and limited range of motion. It is hard to start systemic steroid pulse therapy because of the medical history of ESRD on HD, osteoporosis and T1DM. The shoulder pain was decreased from VAS 8 to 5 at discharge and changed to dull ache. Muscle strength of shoulder was improved but still weak: right shoulder abduction P- grade, shoulder flexion P grade, elbow flexion & extension F+ grade.

Conclusion In this case, we reminded that patient’s chief complain is the most important key to find diagnosis and determine treatment. Considering the clinical course, NA would be considered. Early intervention of physiatrist and appropriate management could prevent unnecessary procedure or surgery. Table 1. Summary table of nerve conduction studies

Table 2. Needle electromyogram findings

Fig 1. Waveforms of nerve conduction studies

C38

Little weight loss related to short NPO period causing SMA syndrome in patient with ALS

Gi-Wook Kim1, Sung-Hee Park1, Myoung-Hwan Ko1, Jeong-Hwan Seo1, Yu-Hui Won1†

Chonbuk National University Hospital, Department of Rehabilitation Medicine1, Chonbuk National University, Research Institute of Clinical Medicine2

Introduction Superior mesenteric artery (SMA) syndrome is a rare cause of small bowel obstruction, characterized by an extrinsic vascular compression of the 3rd portion of the duodenum, between the abdominal aorta and overlying SMA. The most common cause of SMA syndrome is known to be significant weight loss (commonly 33~55% of initial body weight) that leads to loss of mesenteric fat pad. Here we present a case of a male patient with amyotrophic lateral sclerosis (ALS), who developed SMA syndrome abruptly after 5 days of fasting. Case A 61 years old man who was diagnosed with ALS was admitted to the hospital for evaluation and management of blood backflow through the percutaneous radiologic gastrostomy (PRG) tube. He was 176cm tall and weighed 43kg (BMI 13.88 kg/m2). Esophagoduodenoscopy was performed and acute gastric ulcer with recent bleeding was identified. The irritation by PRG tube was thought to the cause of bleeding, therefore it was removed. Patient underwent therapeutic fasting and high dose proton pump inhibitor and 3rd generation cephalosporin was administered intravenously. After 5 days of fasting, patient resumed feeding through Levin tube and percutaneous endoscopic gastrostomy (PEG) tube was inserted 12 days after PRG tube removal. Feeding was resumed through PEG tube starting from 100cc and increased thereby. When the feeding amount reached 200cc, the patient presented vomiting, abdominal distention and tachycardia. Amount of the feeding was adjusted and maintained 100 cc. Body weight was re-measured it was reduced from 43kg (BMI of 13.88 kg/m2) to 38kg (BMI 12.26 kg/m2). We performed abdomen CT and found that the second portion of the duodenum is narrowed at the site between the aorta and the SMA and severe stomach distension above at the level which led to diagnosis of SMA syndrome. The patient underwent jejunal tube insertion, and the amount of feeding through the jenunal tube was gradually increased while maintaining parenteral nutrition. After 2 weeks, presenting symptoms were improved, follow up CT scan was performed to find improvement of duodenal narrowing and stomach distension. Tubogram showed passage of contrast agent through the duodenum without disturbance. Afterwards patient maintained diet by PEG. At discharge, the patient tolerated 500cc of diet and body weight was increased to 43kg. Conclusion In this case, we experienced a rare case of the patient with ALS who developed SMA syndrome despite a short period of fasting and relatively small weight loss. When ALS

patients with malnutrition state present vomiting or abdomen distention after feeding, possibility of SMA syndrome should be on the list of consideration and proper evaluations should be performed in order to provide proper nutritional support.

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Recurrent Complex Regional Pain Syndrome Type I in a Patient with Amyotrophic Lateral Sclerosis

Dae Hee Lee1*, Ju Young Cho1, Kwang Jae Yu1, Jong-Min Kim1, Zeeihn Lee1, Hyunseok Moon1, Donghwi Park1†

Daegu Fatima Hospital, Department of Rehabilitation Medicine1

Introduction Amyotrophic lateral sclerosis (ALS) is a rapidly progressing neurodegenerative disease that involves limb, axial, bulbar, and respiratory muscles. ALS involves degeneration of the motor system combining upper and lower motor neuron signs. Although sensory or dysautonomic signs are not clinically evident, pain can occur in these patients. However, it is usually secondary to severe paresis and immobility, such as frozen shoulder resulting from severe upper limb paresis. In previous research, there have been several reports about ALS patients with complex regional pain syndrome (CRPS). To the best of our knowledge, however, there has been no report about recurrent complex regional pain syndrome in patients with ALS. Here, therefore, we report on an ALS patient with recurrent CRPS, which seemed to be caused by adhesive capsulitis. Case A 60-year-old man with ALS was admitted to our rehabilitation clinic with a two-year history of progressive motor weakness. He also had right shoulder, wrist and hand pain with swelling of the right hand and wrist joint. The three-phase bone scan revealed increased uptakes in the right carpal, metacarpophalageal, proximal interphalageal joint, which is consistent with CRPS. He had recurrence of CRPS in his arm with intervals of 4 months. Discussion CRPS type I is a syndrome with pain and signs of swelling, hyperhidrosis, vasomotor instability and trophic changes in the skin, muscle, and bone in the affected limb, and, by definition, without major nerve injury. There are several theories regarding the pathogenesis of CRPS. Some scientists emphasize the role of the sensitization of the peripheral nerve or spinal cord dorsal horn neuron, whereas some clinicians give weight to abnormalities in the structures of the central nervous system. Recently, some clinicians have emphasized the role of immobilization as a contributing factor for CRPS. It has also been reported that only immobilization without any tissue injury could cause mechanical allodynia in an animal study of a CRPS rodent model. In our case, CRPS type I developed by immobility itself as well as frozen shoulder caused by immobility of the right upper limb. In fact, the patient’s right shoulder pain preceded swelling and pain of the right hand and wrist joint in the clinical history. Therefore, his uncontrolled shoulder pain due to the frozen shoulder combined with immobility seems to have progressed into CRPS type I. The second CRPS seems to have recurred as the frozen shoulder became aggravated due to immobility of the right upper limb after the first steroid pulse treatment. Collectively, in patients with ALS, frozen shoulder is more likely to occur

due to immobility of the upper limb, which may also progress to CRPS. In ALS patients with frozen shoulder, therefore, early treatment, such as an intra-articular corticosteroid injection, PROM and stretching exercises will be necessary to prevent progression to CRPS

Fig 1. Three-phase bone scan of both upper limbs. (A) In the blood flow and pooling phase, increased

venous blood pooling of the right hand was shown compared with the left hand. (B) In the osseous phase,

increased uptake in the right carpal, metacarpophalangeal, proximal interphalangeal joint was shown

compared with the left hand.

C40

Paraplegia after Myocardial Revascularization

Soo-Hyun Soh1*, Ji Hee Kim1†

Wonkwang University School of Medicine & Hospital, Department of Rehabilitation Medicine1

Paraplegia is one of the most severe and rare complications of post-operative coronary artery bypass graft (CABG) surgery, and neurologic injury is known to be a major cause of mortality and morbidity after CABG. We experienced two cases of patients who reported newly developed motor weakness of bilateral lower extremities after CABG surgery. A 61-year-old man underwent emergency CABG surgery for non-ST elevation myocardial infarction (NSTEMI). We performed percutaneous transluminal angioplasty of bilateral common iliac artery. The muscle strength was continued to 2/5 grade measured by manual muscle test. Right lumbosacral plexopathy and left sciatic and femoral nerve injury was diagnosed in nerve conduction study (NCS) and electromyography (EMG). The lumbar magnetic resonance image (MRI) of the patient showed no specific findings including spinal cord infarction. Another 38-year-old man visited emergency room with chest pain and was diagnosed with STEMI. Cardiogenic shock developed during coronary angiogram (CAG) and extracorporeal membrane oxygenation (ECMO) was performed thereby. The intra-aortic balloon pump (IABP) was used after the patient’s vital sign was stable. After the procedure, the strength of both lower extremities was 2/5 grade when measured by MMT. The NCS and EMG results revealed bilateral sciatic and femoral nerve injuries. Paraplegia after myocardial revascularization is rare complication, and spinal cord infarction is reported to be the most common cause of motor weakness. We experienced two patients with paraplegia who were not caused by spinal cord infarction after the intervention.

C41

The change of perilesional scar tissue in a sciatic nerve after injecting steroid.

Jihong Cheon1*, Dong Youl Lee1, Nana Lim1, Geun Su Lee1, Hyun Kyung Lee1, Youn Kyung Cho1, Sung Hoon Lee1†

Kwangju Christian Hospital, Department of Rehabilitation Medicine1

Introduction Disc herniation, pregnancy, piriformis syndrome, hip joint operation and trauma are frequent causes of sciatica, which can lead to palsy of the hamstrings muscles and of all the muscles below the knee with sensory loss in the cutaneous distribution of the peroneal and tibial nerves. In this case, we will introduce the change of perilesional scar tissue in a sciatic nerve after injecting triamcinolone. Case A 41-year-old male patient slipped his Rt. foot a month ago. After that he has felt pain around Lt. thigh spreading to lower leg.both knee and came to hospital. The ankle DTR(++/++), upper motor sign(-), MMT (N/N), full active ROM, SLRT(-/-) were checked and the chief complaint was the pain along the sciatic nerve pathway at the level of VAS5. We performed lidocain TPI in Lt. hamstring muscles on the first day of visit and did sciatic nerve block approaching Lt. piriformis after a week, and it didn't make pain relief. On the day of third visit, the ultrasonography was done around the point of tenderness on thigh and it revealed increased echogenicity followed by acoustic shadow in the sciatic nerve. [Fig.1] MRI study showed delineation of both sciatic nerve without abnormal soft tissue signal intensity. US-guided steroid injection was performed and after two weeks it helped pain relief at the level of VAS2. Furthermore the lesion which had been hyperechogenic was changed into hypoechogenic, like it was swollen. [Fig.2] Conclusion Bubbles and the steroid/anesthetic mixture are a frequent cause of increasing echogenicity. but in this case, the patient not only had medical performance before but also had any bad medical conditions at all. Recalling the structure of the sciatic nerve, which is the bundle of nerve fibers, the lesion might have been the scar tissue around the perineurium as a by-product of injury and must have infiltrated by steroid injection.

Fig 1. Increased echogenicity in the sciatic nerve. A. Long axis, B. short axis

Fig 2. Two weeks after US-guided steroid injection for treatment of sciatic nerve lesion. A. Long axis, B. short

axis

C42

Cardiac Rehabilitation of Arrhythmia Patient with Remained Symptoms after Intervention

Dong Joo Kim1*, Ki Hong Kim1, Min Keun Song1, Hyung Kyu Park1, In Sung Choi1†

Chonnam National University Medical School & Hospital, Department of Physical & Rehabilitation Medicine1

Medication or therapeutic interventions such as radiofrequency catheter ablation (RFCA) could improve Quality of life and exercise capacity in arrhythmia patients. However, some patients complain of cardiopulmonary symptoms or the fear of exercise even after medical management. We report our therapeutic experience of cardiac rehabilitation (CR) in an arrhythmia patient with remained symptoms in spite of the therapeutic intervention. A 52-year-old woman with palpitation and dyspnea in daily life visited cardiovascular center. She was diagnosed as paroxymal atrial tachycardia by electrophysiological study and underwent RFCA. However, her symptoms did not disappear. She was referred to our CR center for the exercise prescription. She received symptom-limited exercise tolerance test (ETT) and was prescribed aerobic exercise of 60% intensity of maximal exercise capacity. She completed the hospital-based CR (twice a week, for 7 months, treadmill walking and running, electrocardiography and blood pressure monitored by physiatrist and physical therapist), and then she has been continuing the home-based CR for 2 months now. During the whole CR period, ETT was conducted 4 times. There was significant improvement of exercise capacity including peak oxygen consumption and exercise duration. Fatigue scale also improved markedly. She does not complain of any symptoms such as palpitation or dyspnea in daily life, and she will return to work soon. CR could improve the exercise capacity and safely relieve the remained symptoms in medically controlled arrhythmia patients.

Table 1. Exercise capacity, duration and fatigue scale at each ETT.

C43

Late Onset Radiation-induced Camptocormia

Bomi Sul1*†, Joon Sung Kim1, Seong Hoon Lim1, Bo Young Hong1, Jae Wan Yoo1

The Catholic University of Korea St. Vincent`s Hospital , Department of Rehabilitation Medicine1

Case Report A 60-year-old male patient presented with back pain which is aggravated by walking or using the stairs. 22 years ago, he was diagnosed with non-Hodgkin’s lymphoma (NHL) with extranodal involvement of spleen. He received chemotherapy containing cyclophosphamide, doxorubicin, vincristine, and prednisone. Relapse occurred in his right axilla with palpable mass in the spleen three years later, and he underwent radiotherapy (30.6 Gy in daily fractions of 1.8 Gy, 5 times per week) without significant acute toxicity. 17 years after completion of radiation therapy, he noticed an insidious onset of backache which increases by walking, and there was a strong tendency to flex the spine forward. He had no other significant medical history and was not taking neuroleptic medication. He did not have any family history of neuromuscular disease or any significant traumatic event. On inspection, a pronounced atrophic change of his lumbar paraspinal muscles was noticed (Figure 1). Sensation and muscle strength were measured normal in all extremities, but he complained of weakness while trying to extend his back. There were no extrapyramidal signs and no bladder or bowel disturbances. Magnetic resonance imaging (MRI) of the spine showed pronounced fatty degeneration of the thoracolumbar paraspinal muscles (Figure 2). In further investigations, electromyography of the paraspinal muscles demonstrated markedly decreased insertional activities. Serum test revealed elevation of creatine kinase (1118) and lactate dehydrogenase (579). A muscle biopsy on mid-thoracic paraspinal muscle was performed, and it only showed results of fatty change. Discussion Camptocormia, also known as ‘bent spine syndrome,’ is characterized by abnormal posture of the trunk with marked flexion of the thoracolumbar spine, which increases during walking and decreases in recumbent position. It is considered as a form of radiation-induced movement disorders, with ‘dropped head syndrome’ being the most common among them. The pathophysiology is not known, although paresis of the paraspinal muscles after radiotherapy is more likely to be of myopathic origin than neuropathy/plexopathy as in paresis of more distal muscles. Most cases of radiotherapy-induced movement disorders are reported in Hodgkin’s disease. According to one previous study, the interval from radiotherapy to diagnosis ranged from 2 to 42 years, with the median of 17 years. The preferential occurrence is more likely to be related to the size of the radiation fields and the doses of the radiotherapy. One study hypothesized that a total dose of conventionally fractionated 30 Gy might be more tolerable for muscular function. There is no cure for camptocormia or ‘dropped head syndrome,’ however; for prevention, sparing of the paraspinal muscles from radiotherapy fields is

desirable. If inevitable, consideration of long-term consequences is needed when prescribing high-dose radiation therapy to the paraspinal region.

Fig 1. Atrophy of lumbar paraspinal muscles and skin fibrosis

Fig 2-1. T2-weighted magnetic resonance imaging showing hyperintense degeneration of the thoracic

paraspinal muscles

Fig 2-2. T2-weighted magnetic resonance imaging showing hyperintense degeneration of the lumbar

paraspinal muscles at the level of L1

C44

The efficacy of complex decongestive physiotherapy for rheumaotid lymphedema: a case report

Woo Ram Koo1*, Chung Reen Kim1†

Ulsan University Hospital, Department of Rehabilitation Medicine1

Rheumatoid lymphedema is known as a rare type of secondary lymphedema, and usually appears many years after the onset of the rheumatic disease, mostly in middle-aged women. Although several hypotheses have been suggested about this disease, but none clearly explained the etiology or pathophysiology of rheumatoid lymphedema. Also there have been several reports of treatment for rheumatoid lymphedema, but mainly on the effectiveness of pharmacological treatments, which were about low dose steroid and etanercept. We report a rheumatoid lymphedema case of a 61-year-old man with bilateral lower limb lymphedema. Although he was taking low dose steroids and etanercept to manage rheumatoid arthritis, his lower limb lymphedema was gradually aggravated and finally referred to the Department of Rehabilitation Medicine. Then he received complex decongestive physiotherapy (CDPT), and his lymphedema improved rapidly within a few days. In this case, he was already taking low dose steroids and etanercept, both of which were known to be effective, but CDPT seemed to be faster and more effective. We hope that this case will increase the interest of lymphedema in patients with rheumatologic disease, and we desire that future research will provide guidance on more effective diagnosis and treatment for rheumatoid lymphedema.

Fig 1. Lymphoscintigraphy with dermal back flow and decreased uptake in the bilateral inguinal lymph

nodes

C45

Case report : The usefulness of IMU-based Gait analysis in patients with disabilities

Jun Hee Lee1*, Aeri Jang1, Hasuk Bae1†

Ewha Womans University Mokdong Hospital, Department of Rehabilitation Medicine 1

On evaluating one’s functional mobility, the most popular and widespread method is

marker-based motion capture technology by using infrared camera. However, there are some limitations inherent in data recruitment in specific settings and environments. It needs to use an array of cameras, marker-based motion capture is not available in patients with handling assistive devices such as walkers, crutches and canes. Because these are considered as obstacles, the accuracy of assesment is decreased. Also, settings with not flattened area such as a patient's home, on the field, or in public is not included in option. One potential solution that has been suggested is to use a markerless motion capture system, for instance, inertial measurement unit (IMU) technology.

Recent study shows utilizing IMU technology to gait analysis with disabled patients who cannot walk without assist. With IMU technology, it becomes enable to carry on quantitative analysis of gait patterns with patients, who needs handling assistive devices. Also, it allows broader range of environments, so gait analysis on the slope or outdoor is available in virtue of its markerless system. IMU-based gait analysis allows quantitative evaluation of disabled patients’ gait pattern and helps determining best fitting assistive devices for rehabilitation.

There are examples of IMU-based gait analysis with in-hospital patiens, who cannot walk independently. Gait patterns were evaluated on transfer day to decide the most suitable assistive device. First, IMU sensor provided to patients’ abdomen, both thigh, shank and foot dorsum. Figure1. And next, calibration of axis was done. Then, patients gait 6m with several assistive devices with video monitoring. During the gait, gait parameters and degrees of hip, knee joint and ankle joints in sagittal, coronal and transverse plane are detected. If the result showed no significant difference between two gait analysis, superior level handling devices was adapted. In contrast, if there was difference, inferior level handling devices was adapted.

Case 1 was patient with chronic subdural hemorrhage at left cerebral convexity, status post burr hole operation, with recent infarction at right side pons. There is no significant differences of gait parameters and joint angle between quad cane gait and monocane gait, as shown in figure 2. So, this patients assistive device was decided to monocane.

Case 2 was patient with spondylodiscitis, L3-4 with abscess at subcutaneous fat layer, L3-4, status post L3/4 spinal abscess removal operation. There was clear difference between walker gait and quad cane gait. The stride length is longer and both knee joint angle(sagittal) is closer to normative range in walker gait, as shown in figure 3. Therefore, in this case, patients assistive device was determined as walker.

In conclusion, IMU-based gait analysis is useful with evaluating disabled patients’ gait patterns quantitatively with accuracy.

Fig 1. IMU-based gait evaluation

Fig 2. Gait parameters and Degrees of hip joint : Quadcane vs. monocane, Case 1

Fig 3. Gait parameters and Degrees of knee joint : Walker vs. quadcane, Case 2

C46

Steroid treatment of TB-IRIS can be changed to NSAIDs: A case report

Hyo Sik Park1*, Jin Seok Bae1, Yong Seong Jeong1, Shin Who Park1, Ja Young Choi1, Kang Jae Jung1, Jong Youb Lim1†

Eulji University Hospital and Eulji University School of Medicine, Department of Physical Medicine and Rehabilitation1

Introduction Tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is an excessive immune response against Mycobacterium tuberculosis, and it may occur in either human immunodeficiency virus-infected or uninfected patients, during or after anti-tuberculosis therapy completion. The incidence of tuberculosis in Korea is 76.8 per 100,000 as of 2016, and tuberculous meningitis accounts for 0.7% of all tuberculosis patients. Treatment of tuberculous myelitis is based on the use of anti-tuberculosis drugs and steroids. Long-term use of steroids may cause immune deficiency, and subsequent TB-IRIS. Treatment for TB-IRIS has not been established yet. Steroids can be tried but discontinuation is not easy even the concern about iatrogenic Cushing syndrome. We report a case of TB-IRIS patient whose steroid treatment was successfully changed to non-steroidal anti-inflammatory drugs (NSAIDs). Case report The patient was a 26-year-old woman who had no significant past medical history. The patient admitted to the Department of Neurology at the address of weakness both legs. Tuberculous myelitis was diagnosed, and the patient was treated with dexamethasone. After acute management, she was transferred to Department of Rehabilitation Medicine and steroids were tapered gradually. Two months after the onset, fever and TB-re-positive sputum were developed. She was a patient with long-term use of high-dose steroids, and was diagnosed with IRIS due to immunosuppression. She was transferred to the Department of Infection and isolated, and steroids dose was increased. Two weeks after, she was transferred to the Department of Rehabilitation Medicine again. Sputum was TB-negative, however intermittent fever was noted. To prevent iatrogenic Cushing syndrome, NSAIDs (Naproxen 500mg twice a day) were tried. About 4-day overlap period, steroids were quitted. There were no fever symptoms afterwards. Side effects of NSAIDs use were not observed. Discussion In general, studies have shown that tuberculosis-induced IRIS can occur in immunocompromised acquired immune deficiency syndrome (AIDS) patients. This patient was HIV-negative, and TB-IRIS appears to be caused by long-term steroids use. In case of TB-IRIS, NSAIDs can be an option which can be used instead of steroids use or can be changed from steroids.

C47

Delayed diagnosis of infectious spondylitis in a patient with hematemesis and melena

Seunghwan Lee1*, Seong-Eun Koh1†

Konkuk University Medical Center and Konkuk University School of Medicine, Department of Rehabilitation Medicine1

Introduction Infectious spondylitis can be caused by various causes. If appropriate treatment is not performed, complications such as spinal cord injury may occur, so early diagnosis and treatment are needed. In this case report, we will present the case of delayed diagnosis of infectious spondylitis in a patient who was admitted to ICU due to hematemesis and melena. Case Report A 66-year-old man with a history of PTSD who underwent orthopedic surgery due to fractures of both tibia four years ago was hospitalized for internal medicine through an emergency room due to hematemesis and melena. About 100mL of hematemesis occurred one week before admission. Two days before and on the day of admission, melena appeared and he came to the emergency room. The patient hit his back during exercise a month ago, and there was no pain afterwards, but the amount of food decreased as the appetite dropped off. Cough, sputum and night sweat were reported 2 weeks before admission and 5kg body weight decreased in one month. Severe anemia was detected in the intensive care unit. Endoscopy was performed to check for gastrointestinal bleeding, and a gastric ulcer with hemorrhage was found. Therefore, epinephrine injection was performed and successful hemostasis was achieved. The pleural effusion was also confirmed and the drain tube was inserted and the antibiotic treatment started. Two days later, the patient was stable and moved to the general ward. On the 4th day of hospitalization, he complained of back pain. At that time, he was able to walk in the ward, so the patient refused further examination for the symptoms. On the 7th day of hospitalization, he complained of severe back pain and weakness in his legs. Therefore, the neurologist examined the patient and conducted whole spine MRI to figure out the cause of weakness. MRI revealed a pathologic fracture of T10 and T11, and an epidural mass compressing the spinal cord.(Fig.1) Therefore, steroid pulse therapy was performed to decompress the spinal cord. Bone biopsy and culture were performed to confirm metastatic cancer or infectious spondylitis, but no specific results were found. The weakness of lower legs gradually progressed to complete paralysis on the 14th day of hospitalization, and decompression surgery was performed. However, the paralysis did not improve, and on the 18th day of hospitalization, the patient was transferred to the rehabilitation department. The state of spinal cord injury was identified as NLI T10, ASIA A. Rehabilitation program was performed, but there was no recovery of motor and sensory function of the lower legs at all.

Conclusion There was a life-threatening medical problem for the patient, and in the process of resolving it, the appropriate evaluation of the suspected infectious spondylitis was delayed. Thus the patient missed the opportunity for early treatment, and the patient became irreversible and complete paraplegia due to spinal cord injury caused by infectious spondylitis.

Fig 1. MRI of spine (contrast-enhanced T1-weighted) : spinous process fracture of T10, a pathologic fracture

of T10 and T11, and an epidural mass compressing the spinal cord

C48

Spinal cord infarction in young female with antiphospholipid syndrome

Ki Yeun Nam1†, Bum Sun Kwon1, Jin Woo Park1, Ho Jun Lee1, Jeong Hwan Lee2, Tae June Park1, Hee Jae Kim1, Tae Yeun Kim1, Sheng Shu Kim1, Yong Jin Cho1*

Dongguk University Ilsan Hospital, Department of Rehabilitation Medicine1, Dongguk University Gyeongju Hospital, Department of Rehabilitation Medicine2

Background Antiphospholipid syndrome(APS) is characterized by venous or arterial thrombosis in the presence of persistent laboratory evidence of antiphospholipid antibodies. APS is quite rare as an etiologic factor for spinal cord infarction (SCI). Case Report This 37-year old woman was admitted to the emergency room with chest discomfort, cough and rhinorrhea on December 17, 2017. The patient had no past medical history that could cause coronary artery disease or pulmonary disease. Immediately after arrival at the hospital, echocardiography and transthoracic echocardiography to evaluate for cardiac embolic source was normal. Chest CT was performed to rule out atypical pneumonia. Chest CT showed both lung pneumonia. The laboratory data showed WBC 14480, CRP 11.58, ESR 38, CK-MB 7.12 (0.0~3.61 ng/mL), Troponin T 0.490 (0~0.014), positive RSV B, lupus anticoagulant antibodies (1.32) and anti-cardiolipin IgM (18.9). Test for another lab was no specific sign. Antiphospholipid syndrome triggered by infection was suspected. On hospital 2days, the patient complained of both lower leg weakness and sensory loss below T8 dermatome. Immediate brain diffusion MRI was performed, there was no evidence of acute infarction or intracranial hemorrhagic lesion (Figure 1). Physical examination showed incomplete motor and sensory impairment below the T8 level, including loss of deep tendon reflexes, and urinary retention. Initial whole spine magnetic resonance imaging performed at hospital 3day after symptom onset didn’t show definite abnormal intramedullary SI or enhancing lesion in spinal cord. Enhance whole spine MRI showed degenerative changes with a herniated disc present at T2-3, T5-6 and T6-7 level pressuring the spinal sac without pressure on the cord (Figure 2). Six days after clinical onset, electrical stimulation of the both median, ulnar, peroneal, tibial, sural nerves showed abnormal findings ; low amplitude on CMAP, of both common peroneal nerve. Somatosensory evoked potentials of lower limbs were no response. Follow up MRI was performed on the 11 day after the first MRI. Enhance T-spine MRI was showed Long segmental intramedullary high SI at T5~conus medullaris. On axial image, the intramedullary high SI is noted at anterior part of spinal cord (Figure 3). Treatment with anticoagulant therapy (warfarin 4mg daily) was given in order to prevent further ischemic attacks that might affect any other organs. The patient showed neurological improvement after rehabilitation.

Conclusions This is the first case of APS triggered upper respiratory infection with spinal cord infarction. The study indicated that APS should also be considered as an evaluation when a spinal cord infarction occurs without any specific cause.

Fig 1. No evidence of acute infarction on DWI

Fig 2.T2-3, T5-6, T6-7 : mild central disc protrusion -> mild thecal sac indentation

Fig 3. Long segmental intramedullary high SI at T5~conus medullaris

C49

Surfer’s myelopathy : case report

Yu Jin Seo 1*, Jong Yoon Yoo1†

Asan Medical Center, Department of Rehabilitation Medicine1

Introduction Surfer’s myelopathy is rare type of non-traumatic spinal cord caused by hyperextension of the back in inexperienced surfers. The etiology of surfer’s myelopathy is unknown, but spinal cord ischemia is presumed to be a main etiology. The aim of this study is to report the two case of diagnosed with surfer's myelopathy and illustrates management and outcomes. Case I A 30 years old previously healthy man took a first surfing and lying on surfboard with repetitive hyperextended of back for about 90 minutes. He developed a back pain, followed by gradual lower extremities weakness, tingling sensation and gait disturbance. Symptoms were gradually progression, he presented with a zero grade lower extremity weakness, loss of sensory up to the level T10, and loss of bladder and bowel function. Magnetic resonance imaging (MRI) demonstrated increased signal on T2 weighted images in T8-T12 level of spinal cord and mild swelling (figure 1. 1-a,b). Diffusion tensor images exhibited heterogeneous mildly increased signal on diffusion weighted images (DWI) with decreased apparent diffusion coefficient (ADC) in T9-T12 level, especially T10 level of spinal cord. He was prescribed high dose steroid and was transferred to a rehabilitation medicine. Two months later, he could perform 60 meter therapeutic ambulation with high walker after wearing both knee brace. And his hip abductor muscle strength is improvement to poor grade and anal tone get better. But fifteen months later, his weakness and sensory loss was continued and he need clean intermittent catheterization. Case II A 22 years old previously healthy man took a surfing lesson in Hawaii. About 30 minutes later, without a traumatic event, he developed acute, severe pain in his back. Within a few minutes, he developed weakness, paresthesia of lower extremity. He was taken to the emergency room and diagnosed with surfer’s myelopathy. Physical examination revealed zero grade lower extremity weakness, loss of sensory up to the level T12, hypoactive of deep tendon reflexes in both legs. MRI demonstrated increased signal on T2 weighted images in T8-conus medullaris level of spinal cord (figure 1. 2-a,b). Diffusion tensor images exhibited increased signal on diffusion weighted images (DWI) with decreased apparent diffusion coefficient (ADC) in T11-12 level. He was prescribed high dose steroid and was transferred to a rehabilitation medicine. One months later, no change of neurologic deficit except voiding difficulty. Twenty five months later, he used wheelchair in similar condition without neurological improvement.

Conclusion Although surfer’s myelopathy is rare disease, the chance of experiencing is expected to increase in Korea because surfing population is increasing. Several cases have been reported fully or near-fully recovered though two cases of this study was poor prognosis. Awareness of this devastated condition will help early detection and active rehabilitation.

Fig 1. Case I (1-a,b), Case II (2-a,b). Sagittal and axial T2-weighted MR images demonstrate hyperintensity of

the spinal cord (arrows).

C50

The Effect of Exoskeleton Robot Training with ExoAtlet on Gait in Incomplete Spinal Cord Injury

Young-Hyeon Bae1*, Kang Woo Lee1,2*†, Da Hee Lee1, Min Ju Kim1, Mi Na Kim1, Jong Seung Lee3, Sol Kwon3

Korea Worker's Compensation & Welfare Service, Rehabilitation Clinical Research Center1, Korea Worker's Compensation & Welfare Service Daegu Hospital, Department of physical and rehabilitation medicine2, Korea Worker’s Compensation & Welfare Service Daegu Hospital, Department of physical therapy3

Purpose This two cases study was to investigate the effect of exoskeleton robot training with ExoAtlet on the gait for establishing the application method and feasting in incomplete spinal cord Injury patients Methods Exoskeleton robot training with ExoAtlet was applied to two selected male subjects with incomplete spinal cord Injury(S1: Thoracic 12 injury, S2: Lumbar 1 injury) who had legs with asymmetry motor and sensory conditions, and gradually increased the velocity distance, stride, height of foot and distance up to self-gait of 100 m without assistance. The foot pressure was measured during each session using foot pressure analyzer for evaluating the gait pattern. After completing the training, the ExoAtlet 's usability was assessed using the 10 satisfaction questionnaires. Results The subject1 was able to gait up to 60 m without assistance at the 6th training, and was able to gait 100 m without assistance at the 13th training. Subject2 was able to gait up to 60 m without assistance at the 9th training and was able to gait up to 100 m without assistance at the 11th training. At standing and gait, the subject1 with below Fair grade (Manual Muscle Test, MMT) of both leg was higher weakness leg more than strong leg on vertical ground reaction force and, subject2 with above Fair grade (MMT) of both leg was higher strong leg more than weakness leg. And the weight support and vertical reaction force were similar between both legs in subject1, but were difference between both legs in subject2. Conclusions Therefore, current exoskeleton robot training with ExoAtlet was showed various abnormal gait pattern and individually different adaptability of robot motion according to the physical condition of the patient due to adjust the motion of the robot. In the future, exoskeleton robot with ExoAtlet need to will be improve and customize for patient's improving quality of life.

Fig 1. Comparison of weight distribution during standing

Fig 2. Comparison of center of pressure during gait

C51

Spinal Cord Infarction With Good Recovery in a Middle-aged Male : Case Report

In-Sik Lee1†, Yong Min Lee1*

Konkuk University Medical Center, Department of Rehabilitation Medicine1

Introduction Spinal cord infarction patients typically present with acute paraparesis or quadriparesis. The severity can vary depending on the level of the spinal cord involved, but permanent and disabling neurologic deficits remain in most. Herein, we report a spinal cord injury patient, who recovered to the level of independent gait and without any other complications through early intensive rehabilitation. Case Report A 54-year old male was presented with sudden onset both leg weakness. He complained mainly sensory change of both lower limbs and progressive lower leg weakness. He denied any changes above the waist level. On initial examination, vital sign was stable and all blood laboratory findings were within normal limits. Motor examination was normal for upper limbs. However, motor strength of lower extremities was found to be between grade zero to fair and distal muscles were weaker than proximal muscles. There were also absent deep tendon reflexes and all sensory modality was impaired below the L3 level. A digital rectal examination revealed impaired perianal sensation with absent anal tone. He also had a urinary dysfunction. In short, his initial condition was in a bed-ridden status. Cerebrospinal fluid study for differentiating inflammatory etiologies was done and found a slightly increased protein level at 59.8mg/dL. MRI of the spine was performed that showed central signal change in T12-L1 cord levels with surrounding edema and there was no severe degenerative change or space occupying lesion and cord compression lesion (Figure 1). The patient was started on aspirin and corticosteroids with a possibility of a demyelinating spinal cord lesion. To differentiate an ischemic lesion, he underwent additional MR angiography (MRA) and diffusion-weighted imaging. Although no vascular anomalies were discovered in MRA, there was a diffusion-hyperintense infarct of the spinal cord at distal thoracic level (Figure 2). After that, intensive rehabilitation including aquatic therapy was initiated to help build muscle strength and improve balance. On day 11 of admission, some improvement was observed in the power of lower limbs and he was able to sit up with a minimal assist. By one month, motor recovery was made up to normal grade except for ankle dorsiflexion and big toe extension. In addition, there was no neuropathic pain without addition of analgesic medications. He was able to sit up independently and ambulate independently with application of a customized ankle-foot orthosis, while voiding and defecation difficulties were resolved with proper management and care. Also until 3 months after the initial diagnosis, he had not experienced any recurrence or aggravation.

Conclusion Spinal cord infarction tends to have a severe prognosis with permanent and disabling sequelae. This report is a rare case of spinal cord infarction at distal thoracic level who has a good recovery without any complications.

Fig 1. T-L spine MR T2 weighted image : Segmental swelling and abnormal T2 signal in central zone of conus

medullaris at T12 - L1 levels

Fig 2. Diffusion-weighted image : A high signal intensity lesion in the distal spinal cord from mid-T12 level to

conus medullaris and some cauda equine

C52

Spinal cord infarction after surgery of aortic dissection: Case Report

Sung Hyun Kim1*, Jong Yun Yoo MD1†

Asan Medical Center, Department of Rehabilitation Medicine1

Introduction Both surgical and endovascular repair of an aortic aneurysm or dissection can lead to spinal cord infarction (SCI) because the vascular supply of the spinal cord largely originates directly from the aorta. SCI in patients undergoing aortic repair is related to the ischemia or occlusion of the anterior spinal artery. The rate of SCI in patients undergoing aortic repair seems to vary depending on the presence and location of dissection, aneurysm rupture, and type of repair. Case presentation A 44-year-old man was treated ascending aorta replacement due to aortic dissection type B in 2006. During the follow up without any symptoms, the thoracoabdominal aorta was increased to 64mm in 2016. He underwent replacement of thoracoabdominal aorta from just distal aortic arch to iliac bifucation in November 2016. Circulatory arrest was used for distal aortic arch replacement. Distal aortic arch was anastomosed with reverse elephant trunk graft. Arch 4 branch graft was used to bypass intercostal in descending thoracic aorta and inferior mesenteric artery. Coselli graft was bypassed with bilateral renal arteries, superior mesenteric artery, celiac arteries. The operation took almost 11 hours. On examination both the upper limbs had normal tone and power. Biceps brachii, triceps brachii reflexes were normoactive. Both the lower limbs had reduced tone and the power was of Medical Research Council (MRC) grade 0/5. Both knee and ankle jerks were decreased with equivocal plantar response. There was no sensation including pain, light touch and temperature from T5 level. He conducted clean intermittent catheterization due to urinary retention. Anal tone was decreased and there was no anal sense. Magnetic Resonant Imaging (MRI) was taken 3 months later after paraplegia. Myelomalacia with mild atrophy below T5 level was observed. Diffuse heterogenous T2 signal intensity was revealed along the spinal cord below T5 level. It is considered to be a sequel of ischemic injury of spinal cord. Conclusion Surgical repair of an aortic aneurysm or dissection could cause in reduction of spinal arteries, resulting in spinal cord infarction. In addition, these surgeries could cause hypoperfusion of spinal artery because of long operation time.

Fig 1. MRI (sagittal T2-weighted image) of the thoracic spine showing myelomalacia at T6 level with mild

atrophy at below T6 level

C53

Management of Orthostatic Hypotension with Complete Cervical Spinal Cord Injury: A Case

Seung Hee Han1*, Ga Yang Shim1, Jong Kyu KIM1†

Seoul Medical Center, Department of Physical Medicine and Rehabilitation1

Introduction In patients with cervical and upper thoracic spinal cord injury, some autonomic dysfunctions may occur. Orthostatic hypotension is one of the factors that interfere with comprehensive rehabilitation and result in a decrease of the activities of daily life. We experienced a case of cervical spinal cord injury with orthostatic hypotension in our rehabilitation setting and report it. Case A 26-year-old man has visited an emergency room for upper and lower limb weakness. On Magnetic resonance image, he was diagnosed epidural hematoma from C4 to T2. At hospital days 7, he had got laminectomy C5-T1, epidural hematoma removal, and posterior fixation. Finally, he got C4 spinal cord injury with AIS A. He measured 3/5 of both elbow flexors and wrist extensors in the manual motor test. However, he was completely paralyzed in the other limbs and lost his sensation below C4 dermatome area. He could not maintain sitting because he fainted and decreased his blood pressure. He had a third degree of pressure ulcer in coccyx for a long time with a bedridden state. At the initial day of rehabilitation, resting blood pressure was measured 130 / 80mmHg, but when he trained tilt table standing exercise at 40 degrees, he fainted, and his blood pressure dropped to 80 / 40mmHg. He could not use a wheelchair because of severe hypotension when sitting up more than 40 degrees. We administered proper salts and hydration, and applied an abdominal bandage and lower limb compression stockings. As pharmacological treatments, Fludrocortisone (0.1mg), mineralocorticoid for blood volume expansion and midodrine (2.5 mg), an alpha-adrenergic agonist for peripheral vasoconstriction were administered. However, it gave no effect to his function. When he did a tilt table exercise, he had a sudden drop in blood pressure and dizziness. So he could not do tilt table exercise at even 50 degrees. We gave him a passive range of motion exercise using motormed sitting in a wheelchair supporting his back by 45 degrees. He continued to motomed exercise with a gradually increasing angle within the tolerable range. At day 20 of rehabilitation, and starting motormed exercise after 14 days, tilt table exercise still resulted in blood pressure drop and dizziness at 50 degrees, however, during the motomed exercise, he could tolerate sitting up 80 degrees for more than 30 minutes. At ordinary times, he could ambulate wheelchair with sit up position more than 30 minutes. Conclusion We experienced a patient with cervical spinal cord injury with severe orthostatic hypotension. In our experience, passive range of motion exercise using motormed was the most effective treatment, rather than any kinds of medication. Larger sized

prospective studies would be required to set up comprehensive rehabilitation programs for a patient with uncontrolled orthostatic hypotension with high cervical spinal cord injury. Table 1. Results of Manual Muscle Test

Table 2. Summary of Orthostatic Hypotension Management

C54

A Subcalcaneal Bursitis developed after Excessive Walking : A Case Report

Jungsang Lee1*, Yong-taek Lee1†, Kyung Jae Yoon1, Jong Geol Do1, Kun Woo Kim1, Jin-Tae Hwang1

Kangbuk Samsung Medical Center, Department of Rehabilitation Medicine1

Introduction Plantar heel pain is a common clinical problem and has been attributed to numerous causes. Among them, subcalcalneal bursitis is very rare but it sometimes reported as a potentially plausible cause of plantar heel pain. This condition is likely to be misdiagnosed as plantar fasciitis, which may result in unnecessary treatment such as extracorporeal shock-wave therapy. The subcalcaneal bursa is located between the plantar fascia and the plantar fat pad, and mechanical overload is known to cause an inflammatory reaction on it. We present a case of left subcalcaneal bursitis occurred by excessive walking and diagnosed by ultrasonography and magnetic resonance imaging with contrast-enhancement (CE-MRI). Case report The patient (54-year-old woman) with left plantar heel pain and swelling for 3 months visited our outpatient clinic (Fig.1). She performed excessive walking exercise (3-4 times a week, 4-5 hours a day) for one month before symptom onset. The patient had no history of trauma. She complained of severe pain (numeric rating scale 10), which had been gradual in onset, worsening at night, aggravating by ambulation and physical training. On physical examination, there was prominent tenderness and diffuse swelling with warmth in the plantar heel. Routine blood test and plain foot radiography were all negative. Ultrasonography showed diffuse swelling and hypoechogenecity in the left plantar fat pad. Doppler image showed remarkable hypervascularity in the plantar fat pad However, there was no significant abnormal findings in plantar fascia (Fig.2A,2C). To rule out other concomitant pathologic conditions, magnetic resonance imaging with contrast-enhancement (CE-MRI) was conducted. T2 weighted images showed a 3.0x2.5x0.7cm sized fluid-filled lesion with high signal intensity in the subcalcaneal bursa. Post-contrast scan of sagittal image demonstrated peripheral rim enhancement (Fig.3A,3B). Non-steroid anti-inflammatory medication and cyrotherapy were started. Additionally, we restricted daily activity such as walking and applied silicon heel pad to avoid impact on heel pad area. After one month, patient’s symptom was much improved (numeric rating scale 3). On palpation, tenderness and swelling were decreased. Conclusion The case we described here presents a rare case of subcalcaneal bursitis, caused by excessive walking and diagnosed by ultrasonography and MRI.

Fig 1. Swelling of left plantar heel was observed.

Fig 2. Left plantar heel showed a diffuse swelling and hypoechogenicity between the plantar fascia and the

plantar fat pad on ultrasonography (A) and demonstrated hypervascularity on doppler image (C). The right

plantar heel had normal appearance (B,D).

Fig 3. Magnetic resonance image with contrast-enhancement of left foot shows findings of subcalcaneal

bursitis. (A) T2 weighted image of right foot demonstrated a 3.0x2.5x0.7cm sized fluid-filled lesion (open

arrow) with high signal intensity on the subcalcaneal area. (B) On post-contrast scan of sagittal image,

enhancement (black arrow) is observed in the same area.

C55

Remitting Seronegative Symmetrical Synovitis with Pitting Edema: a case report

Jong Won Lee1*, Kyeong Eun Uhm1, Jongmin Lee1,2†

Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, Department of Rehabilitation Medicine1, Konkuk University Medical Center; the Graduate School of Konkuk University, Seoul, Department of Rehabilitation Medicine2

Introduction Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is a rare condition that occurs in elderly individuals. It is characterized by sudden onset of bilateral symmetrical distal tenosynovitis that accompanied by obvious swelling of the hand with pitting edema and absence of rheumatoid factor (RF). This disease entity sometimes are presented as overlap syndrome with other rheumatic diseases, and needed to be differentiated from that. However if the diagnosis is confirmed, the response to treatment is good. The purpose of this report is to describe the case of RS3PE syndrome presented with bilateral hand dorsum edema in middle-aged woman. . Case Report A 54-year-old woman visited the outpatient clinic with bilateral hand dorsum edema. She did not have a history of specific medical and family history, but problems began to occur from 6 weeks ago. At the time of outpatient visit, edema was observed in dorsal side of bilateral wrists and hands, and the degree of swelling was more severe on the left side. There was no pain and heating sense in the swollen hands. Physical examinations revealed normal motor and sensory functions in the upper and lower extremities, and range of motion of all wrist and finger joints were preserved. In the initial blood test, there was no abnormality other than mild elevation of C-reactive protein (CRP). Initially, NSAIDs were prescribed. However, after taking one week of medication, multiple arthralgia of both wrists, hands, hips, knees, and ankles were developed. At the same time, level of inflammatory marker was markedly increased (Erythrocyte sedimentation rate 21mm/h, CRP 7.12 mg/dl). However, RF and anti-cyclic citrullinated peptide antibody were normal. In the ultrasonographic examination, tenosynovitis of the extensor tendons of both wrists was observed. Additionally, diffuse subcutaneous layer and fascial edema of dorsal side of wrist was observed in outside magnetic resonance imaging. Based on clinical findings, she was diagnosed as RS3PE syndrome, and prescribed prednisolone 10mg daily. The edema and polyarthralgia were dramatically improved, and inflammatory marker was rapidly normalized within 2 weeks after taking prednisolone. Follow up ultrasonographic examination showed no tenosynovitis of extensor tendons of both wrists. The prednisolone was slowly tapered out during 4 months, and she is currently doing well without symptoms until 4 months after steroid off. Conclusion RS3PE syndrome is an uncommon disease and is still uncertain about the cause and diagnostic criteria. If both hands are suddenly swollen with findings of distal tenosynovitis

and negativity of RF, RS3PE syndrome should be considered after exclusion of other rheumatic disease. In addition, if RS3PE is suspected, a steroid can be used for both diagnostic confirmation and treatment.

C56

Clinical presentation of acute calcific tendinitis of the longus colli muscle

In-Sik Lee1†, Minsun Kim1*

Konkuk University Medical Center, Department of Rehabilitation Medicine1

Introduction Acute calcific tendinitis of the longus colli tendon is an aseptic inflammation of the longus colli tendon that characterized by acute onset of posterior neck pain, neck stiffness and when more advanced, dysphagia or odynophagia. Awareness of its existence is crucial in the differential diagnosis, because many other conditions, such as retropharyngeal abscess, disc herniation, oro-pharyngeal neoplasm or meningitis, show similar clinical features. We present a case exhibiting acute onset of neck pain that over the next few days progressed to involve dysphagia. Multiple imaging studies were performed that eventually supported the diagnosis of acute calcific longus colli tendinitis. Case Report A 51-year-old woman presented with occasional posterior neck pain and left side neck stiffness accompanied by dysphagia. One morning, she woke up with neck pain that was much worse than her usual neck pain. There was no history of trauma, unusual physical exertion or strain to the neck. The pain continued to worsen the next day, when she also noticed mild restriction of her neck movements and she developed dysphagia for both solids and liquids. With her neck pain and stiffness worsening, an MRI of the neck with contrast was performed to look for prevertebral or epidural abscess. Imaging revealed severe prevertebral soft tissue swelling without finding of abscess (figure 1). CT scan of the neck was performed to confirm the presence of calcifications in the longus colli tendon. The CT of the neck was consistent with 1.3x0.7x1.2cm sized cloud like high density calcification deposition at just inferior aspect of atlas tubercle (figure 2). Treatment with NSAIDs, low doses of corticosteroids and Philadelphia brace relieved the symptoms within 48 hours. Four week after treatment she was doing well, able to tolerate a regular diet, and move her neck without pain. Eight weeks later she continued to be asymptomatic. Follow-up CT showed markedly decreased amount of calcification at longus colli tendon deposition (figure 3). Conclusions Acute calcific longus colli tendinitis is an underreported entity in the literature and clinicians should become aware of its existence. We would like to raise awareness of this important mimicker as an often misdiagnosed cause of acute neck pain. It may lead to unnecessary antibiotics administration and interventions in the retropharyngeal space. Key words calcific tendinitis, longus colli, neck pain, dysphagia

Fig 1. Initial C-spine MRI. a. Contrast enhanced T1W sagittal view. b. T2W sagittal view. c. T2W transverse

view. There is a severe prevertebral soft tissue swelling (arrowhead) without evidence of abscess or

inflammation, and proximal fibers of the longus colli tendon have calcification (arrow).

Fig 2. Initial Neck CT. a. sagittal view. b transverse view. Both of them reveal high density calcification

deposition (arrow) at just inferior of atlas tubercle.

Fig 3. Follow-up Neck CT. a. sagittal view. b. transverse view. Both of them reveal markedly decreased

amount of calcification (arrow) at longus colli tendon deposition

C57

Combination of botulinum toxin with shock wave therapy relieves sternocleidomastoid muscle fibrosis

Dong Rak Kwon1*†, Gi Young Park1

Daegu Catholic University Medical Center, Department of Rehabilitation Medicine1

Background Congenital muscular torticollis (CMT) results from the fibrosis of the sternocleidomastoid (SCM) muscle. In neglected adult cases, the treatment of this entity is more controversial. Extracorporeal shock waves therapy (ESWT) might be responsible for the anti-scarring effect. Botulinum toxin type A (BTA) could be a promising agent against SCM fibrosis in rabbit CMT. We report a case of persistent adult CMT treated with ESWT and BTA. Case A 26-year-old man presented a neck mass of right SCM muscle with twisting of the head to the left. Despite physical therapy, the patient still persisted with torticollis. The passive cervical rotation range of motion (PCRROM) of the affected SCM was measured using an arthrodial protractor. The patient had 70 degrees of PCRROM on the right and 90 degrees on the left. Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was 16.25 at pre-treatment. Hyperechogenic nodular muscle thickening and low signal intensity was shown at the middle and lower portion of right SCM muscle on ultrasound and magnetic resonance image (MRI) (Fig.1). 20 units of BTA were injected into the fibrosis tissue of right SCM muscle and ESWT was performed once a week for 3 weeks. At each session, An energy flux density of 0.1mJ and 1000 impulses were administered on the fibrotic portion of right SCM muscle. After three sessions of ESWT, PCRROM of right SCM was increased from 70 degree to 90 degree, right SCM fibrotic tissue on ultrasound was decreased from 241.72 cm2 to 108.72 cm2 (Fig. 2), TWSTRS score was reduced from 16.25 to 4.5 and an improvement in head posture (Fig. 3). Conclusion This is a first case report combination of BTA with ESWT shows sufficient improvement in neck range of motion and head posture through relieving SCM muscle fibrosis.

Fig 1. Transverse B mode and neck MRI image of affected SCM muscle at pre-treatment. (A) image shows

diffuse enlarged hyperechoic mass (arrowheads). (B) T1 weighted image shows low signal intensity mass

(arrow) (C) T1 weighted image shows low signal intensity mass (arrow). SCM; sternocleidomastoid, C;

carotid artery.

Fig 2. Transverse B mode image of affected SCM muscle. (A) image shows diffuse enlarged hyperechoic mass

(arrowheads) and CSA was 241.72 cm 2 at pre-treatment. (B) image shows reduced hyperechoic mass

(arrowheads) and CSA was 108.72 cm 2 at post-treatment. SCM; sternocleidomastoid, C; carotid artery.

Fig 3. (A) Typical head posture in a 26-year-old man patient with right sided torticollis. (B) Same patient at 6

weeks after ESWT with BTA treatment. ESWT: Extracorporeal shock waves therapy, BTA; botulinum toxin

type A

C58

Ischaemic Lumbosacral Plexopathy Following Iliac Artery Occlusion in Young Patient: A Case report

Yunsoo Soh1†, Hee-Sang Kim1, Jong Ha Lee1, Dong Hwan Yun1, Jinmann Chon1, Yong Kim1, Haneul Jang1*

Kyung Hee University Medical Center, Department of Rehabilitation Medicine1

Acute common iliac artery occlusive disease is rare in young adult. Lumbosacral plexopathy usually caused by intervertebral disc herniation. Other causes are epidural compression from traumatic injury, primary and metastatic neoplasms, and epidural haematoma. Lumbosacral plexopathy secondary to iliac occlusive disease is rare and can mimic cauda equina syndrome or lumbosacral radiculopathy. We describe a rare vascular cause of unilateral ischemic lumbosacral plexopathy representing acute paralysis of lower limb in young patient. A 35-year-old man presented to the emergency department with Right lower limb weakness. He only has past medical history of hypertension without any medication. He complained of paresthesia and weakness in his right leg. Whole aorta and lower extremity angio CT were done. The findings were thoraco-abdominal aortic dissection, left external artery occlusion and right iliac artery total occlusion. Thoracic endovascular aortic repair and both bilateral iliac artery stent insertion were done. Manual motor test on his right lower extremity was trace grade otherwise other extremities were good grade. Right lower limb reflexes were absent and there was impairment of sensation in L2 dermatome and below. Needle electromyography and nerve conduction studies were done on right legs and bulbocavernosus muscle. Results showed consistent with right lumbosacral plexopathy with impaired bulbocavernosus reflex. We report a rare case of a 35-year-old young male with lumbosacral plexopathy caused by iliac artery occlusion.

C59

Successful treatment of tetanus-induced dysphagia with facial massage: A case report

Yong Sung Jeong1*, Jin Seok Bae1, Hyo Sik Park1, Shin Who Park1, Ja Young Choi1, Kang Jae Jung1, Jong Youb Lim1†

Eulji University Hospital and Eulji University School of Medicine, Department of Physical Medicine and Rehabilitation1 Introduction Tetanus is an infection characterized by muscle spasms, and begins in the jaw muscles, of which findings also known as lockjaw or trismus. The spasms also affect the facial muscles and progress to the rest of the body. Prolonged muscular action causes powerful and painful contractions of muscle groups. Many patients complain of dysphagia due to mastication disorder. Manifestations of tetanus are usually managed with muscle relaxants only. The normal time course of tetanus is variable, but severe symptoms can persist for more than 2 months. Some patients are treated with botulinum toxin for dysphagia, however several complications such as decreased mastication force, bruising, headache, and the limitation of smile were reported. We report a patient with oropharyngeal dysphagia due to tetanus, who was successfully treated with facial muscle massage and muscle relaxants. Case Report An 84-year-old female patient admitted to the Department of Otorhinolaryngology because of tongue mass and pain. After admission, she exhibited whole body rigidity, desaturation and the loss of consciousness. Tetanus was diagnosed and she was transferred to the intensive care unit. She was treated with intravenous metronidazole 500mg and tetanus immunoglobulin plus Td vaccination. After she regained consciousness, she was educated to relax facial muscles. In spite of medical treatment, she could not open the mouth. After she moved to the general ward, she was transferred to the Department of Rehabilitation Medicine. Initially videofluoroscopic swallowing study (VFSS) was not possible because she could not open the mouth and chew. Treatment with facial massage and muscle relaxants (diazepam 2mg per day) was started. To re-establish the proper length and flexibility of muscles, we used effleurage, kneading, friction, and stretching. Approximately 30-minute facial massage of mastication muscles such as temporalis, pterygoid, and masseter muscles was performed twice a day. After 4 weeks of treatment, she could open the mouth. Trismus was remarkably reduced. She could undergo VFSS. Oral transit time was 4.08sec, and she could chew food 13 times in 10 seconds. Vallecular and pyriform residue were grade 3, and penetration-aspiration score (PAS) was grade 6. She continued to get treatment of facial massage and muscle relaxants. Follow up study showed that oral transit time was 3.14sec, and she could chew food 15 times in 10 seconds. Vallecular and pyriform residue were grade 2, and PAS was grade 3. Currently, she can eat some solid food such as banana and grape.

Conclusion In the present case, facial massage was effective to improve jaw opening and mastication for the patient with tetanus. After the massage the patient was able to open the mouth, the masticatory movement was improved, oral transit time was shortened, and vallecular and pyriform residue has decreased. Tetanus-induced dysphagia could be treated with muscle-oriented approach.

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A small angioleiomyoma of the elbow: a case of unusual pain

Kwang Jae Lee1,2*†, Yong-Soon Yoon1,2, Young-Cheol Yun1

Presbyterian Medical Center, Department of Rehabilitation Medicine1, Presbyterian Medical Center, Medical Device Clinical Trial Center2

The Angioleiomyoma is a benign smooth muscle tumor that originates in the tunica media of the veins. It would be found in the dermis, the subcutis, or the superficial fascia of the anywhere in the body and is most often seen in the extremities, particularly the lower leg. The typical lesion is a small, slowly growing, round, but firm and mobile nodule. Pain is the most common clinical symptom and is thought be caused by the contraction of smooth muscle leading to focal ischemic pain. We report a case of angioleomyoma located in the lateral aspect of the elbow, which was mistaken for extradigital glomus tumor after history taking, physical examination, and ultrasound. With pinpoint tenderness, allodynia, worsening sharp pain in cold exposure for several years, the patient was referred for a further evaluation, and the lesion was 0.6 cm sized well-circumscribed mass in the lateral elbow with arterial signal on color Doppler by ultrasound and finally diagnosed as angioleimyoma following complete excision and pathologic evaluation. The symptoms were subsided and the patient was relieved. This present case highlights the importance in considering this rare disease in the differential diagnosis of the elbow pain.

C61

Pain near solitary pulmonary nodule: a case report

Hyo Sik Park1*, Jin Seok Bae1, Yong Seong Jeong1, Shin Who Park1, Ja Young Choi1, Kang Jae Jung1, Jong Youb Lim1†

Eulji University Hospital and Eulji University School of Medicine, Department of Physical Medicine and Rehabilitation1

Introduction Thoracic pain is common and has various etiologies. Patients with cardiac, pulmonary, and aortic origins mainly visit emergency department. Gastroesophageal reflux disease, pleuritis, herpes zoster, and musculoskeletal causes are usually not categorized as life-threatening. Malignant lesions of lung can cause thoracic pain, however pain associated with solitary pulmonary nodule (SPN) is not considered because more than 90% of SPN are detected as incidental findings. We report a case of thoracic pain of which site is near pulmonary nodule. Case report A 66-year-old female patient visit rehabilitation department with left upper back pain which was developed about 6 months earlier. Pain is located on medial side of scapula and on the upper thoracic level. Some tenderness was noted. No other symptoms are present. She and her husband were non-smokers, but her father died from lung cancer. Chest CT found 12mm-sized SPN in the left upper lobe of the lung and no abnormality in the bony thorax. Because her pain sustained even with medication, ultrasound-guided thoracic paravertebral space injection was done. After that the pain was decreased. However the pain still remained and was controlled with medication. Follow-up CT will be undertaken about 3 months later. Conclusion Although this SPN need to be confirmed by follow-up CT and even by biopsy, there was no other explanable causes for thoracic pain. Thoracic pain might be evaluated while thinking about the possibilities of SPN-related causes.

C62

Successive Acute Calcific Tendinitis on Different Sites: Three Cases Report

Seung-Wook No1*, Yong Min Choi1, Du Hwan Kim1†

Keimyung University Dongsan Medical Center, Department of Rehabilitation Medicine1

Introduction Acute calcific tendinitis (ACT) is a benign painful inflammatory disorder characterized by the resorptive process of calcific deposit following the formation of calcium hydroxyapatite crystals in tendons. It can occur at various sites, especially shoulder or hip joint. ACT involving the lateral epicondyle of humerus and cervical spine is very rare. Also, there have been few reports demonstrating successive ACT at different sites. We report three female cases with successive ACT, one with the lateral epicondyle after subscapularis, another with supraspinatus after flexor carpi ulnaris, and the last with iliopsoas following longus colli. Case Three females with successive ACT were studied. A summary of the findings in three patients is shown in Table 1. Figure 1 and 2 demonstrate the imaging studies in case 1 and 3 respectively. Case 1 is described representatively. A 55-year-old female presented with one-day history of acute right shoulder pain. She had no history of recent trauma or vigorous sports activity. Active shoulder movement was impossible because of severe pain. Laboratory study revealed increase of ESR and CRP level without leukocytosis. A plain radiography revealed homogenous ill-defined calcifications in the region of subscapularis tendon (Fig. 1A). MRI showed calcific deposit with muscle edematous change in the subscapularis (Fig. 1B). Based on the clinical presentation and imaging findings, a diagnosis of ACT of the subscapularis was made. After administering NSAID, her symptoms were marked resolved within 2 days. Follow-up plain radiography at 2 months showed complete solution of calcific deposit (Fig. 1C). Two years later, she presented with one-day history of acute right elbow pain. On examination, there was severe focal tenderness over the lateral epicondyle with local heatness. A plain radiographs showed curvilinear calcification adjacent to the lateral epicondyle (Fig. 1D). Ultrasonography revealed hyperechoic calcific foci of the common extensor tendon at the lateral epicondyle (Fig. 1E). With the barbotage procedure and peritendon steroid injection (a mixture with 2cc 1% lidocaine and 20mg triamcinolone acetonide), the patient had marked improvement of her symptoms within 2 days with no recurrence at two-months follow-up. Follow-up radiographs showed near complete dissolution of the calcific foci with faint residual linear calcifications (Fig. 1F). Discussion In conclusion, we report three female cases of successive ACT at different sites including unusual site such as elbow or neck. The bibliographic references for the successive ACT are limited. However, it is estimated that the incidence of successive ACT is not uncommon, considering the fact that nearly every tendon in the body is vulnerable to

calcific tendinitis. Our cases may enhance the understanding of various clinical manifestations of ACT for the clinicians. Table 1. Summary of the clinical findings

Fig 1(Images of case 1). (A) A radiograph of the right shoulder demonstrates 10 mm sized homogenous ill-

defined calcifications (arrow) in the region of subscapularis tendon. (B) MRI shows calcific deposit (arrow)

with muscle edematous change (arrowhead) in the subscapularis. (C) Two-months follow-up radiograph

reveals resolved calcific mass. (D) A radiograph of the right elbow demonstrate 9 mm sized ill-defined

calcification (arrows) in the common extensor tendon. (E) Ultrasonography reveals hyperechoic calcific

deposit (arrows) with increased vascularity in the common extensor tendon. (F) Two-months follow-up

radiograph demonstrates partial dissolution of the calcific foci with residual linear calcifications (arrow).

Fig 2(Images of case 3). (A) A radiograph of cervical spine demonstrates small calcific deposit (arrow) in the

C2 body anteriorly with the widening of prevertebral soft tissue space. (B) MRI reveals calcific deposit

(arrow) with muscle edematous change (arrowhead) in the longus colli. (C) Coronal view of hip MRI shows

calcific deposit (arrow) around anterior inferior iliac spine with muscle edematous change (arrowhead) in

the iliacus.

C63

A large epiglottic cyst on videofluoroscopic swallowing study

Sung-Hwa Ko1*†, So Jung Kim1, Ju Hynn Son1, Eui-Suk Sung2

Pusan National University Yangsan Hospital, Department of Rehabilitation Medicine 1, Pusan National University Yangsan Hospital, Department of Otorhinolaryngology2

A 49-year-old man with Wernicke's encephalopathy visited our hospital to manage general weakness. His weight was reduced more than 10 kg in recent months and his body mass index was 14.5kg/m2. He reported dysphagia with solid and liquid diets with residual sensation and aspiration symptom. He was referred to our dysphagia clinic to perform videofluoroscopic swallowing study (VFSS) for evaluation. Before starting the VFSS, large cyst like lesion was observed at vallecular space in lateral view (Figure 1). On VFSS, the lesion was movable and caused dysphagia. During swallowing, the cyst was going through the upper esophageal sphincter to enter esophagus and disturbed the passage of foods. It also interfered folding of the epiglottis and resulted in residue in vallecular space and it caused aspiration during swallowing in liquid diets(Video 1, Figure 2). Neck computed tomography imaging and laryngoscopy revealed a giant epiglottic cyst (Figure 3). Surgery was done to remove the epiglottic cyst and the cyst was measured about 40mm in diameter. Follow-up VFSS was performed on postoperative day 4. On VFSS after surgical resection, oropharyngeal movement showed almost normal and dysphagia was nearly resolved (Video 2). Epiglottic cysts in adults are relatively rare lesion. The pathophysiology of acquired laryngeal cysts is thought to be associated with chronic mucosal inflammation, resulting in the obstruction and dilatation of mucus ducts. Many of the laryngeal cysts are usually asymptomatic, but the presenting symptoms vary according to their size and location. Large laryngeal cyst may present with foreign-body sensation, voice change, dysphagia or dyspnea. Surgical resections should be considered in patients with dysphagia or dyspnea.

Fig 1. A cyst like lesion was observed in fluoroscopy.

Fig 2. The cyst was going through the upper esophageal sphincter to enter esophagus and caused dysphagia

Fig 3. a) An oval shape epiglottic cyst on sagittal neck computed tomography b) Laryngoscopic view of a

giant epiglottic cyst.

C64

Diffusion tensor tractography of cognitive impairement in neuromyelitis optica

Ah-Ra Cho1*, Hye-yeon Park2, Joo Hyun Park2

St. Paul Hospital, The Catholic University of Korea, Department of Rehabilitation Medicine1, The Catholic University of Korea Seoul St. Mary`s Hospital , Department of Rehabilitation Medicine2

Introduction Nueromyelitis optica spectrum disorder(NMOSD) is an immune-mediated disorder which affect optic nerve, spinal cord and specific brain area. The cognitive deficits in NMO showed variable relationships with brain lesions, white matter diffusion abnormalities but cannot be fully explained by a conventional magnetic resonance image (MRI) measure. The aim of this report was to investigate changes of white matter related to cognitive dysfunction in a NMO patient by means of diffusion tensor tractography (DTT). Case Report A- 34-year old woman presented blurry vision on right visual field. Aquaporin-4-immunoglobulin-G (AQP4-IgG) was positive and autoimmune serological tests were unremarkable. She was diagnosed with NMOSD. She prescribed steroid for as pulse therapy and maintenance for one month. Her visual acuity showed improvement during the first month of treatment. However, 3months after discontinuing steroid, the patient experienced quadriplegia with mental deterioration. Her brain MRI demonstrated T2 high signal intensities involving both cerebral hemispheres and upper brainstem, especially involving subcortical white matters suggesting acute excerbation state of NMO. Intravenous steroid pulse therapy and plasma exchanges were performed and she regained her alertness. Intra venous immunoglobulin was supplementary administrated. One month after acute management, her motor power was MRC grade 3 on right upper and lower extremities and grade 1 on left side extremities. She achieved 14 score in Korean Mini-Mental State Examination (K-MMSE) regardless of her prior high educational level as dentistry doctor. She was transferred to department of rehabilitation and received physical and occupational therapy include cognitive rehabilitation. After one month, her motor power picked up MRC grade 4 on all extremities but showing dynamic instability on left weight bearing. She scored full marks in the K-MMSE but appeal decreased attention, especially to visual stimulation. She received neuropsychological test and follow up brain MRI. Her performance showed average range in Train Making and forward Visual Span test but presented moderately atypical disability in backward Visual Span test. On tractography using DTI data, right CST demonstrated small volume compared to left. Her Cingulum and Uncinate fasciculus showed decrease volume and FA values on left hemisphere. However, no fibers projected to medial and orbitofrontal cortex from external capsule were observed on right IFOF despite of relatively preserved adjacent crossing tract of UF (Figure 1,2).

Fig 1. Uncinate fasiculus and Inferior fronto-occipital fasiculus

Fig 2. Corticospinal tract and Cingulum

C65

The value of unilateral weight training for peripheral vascular disease.

Dong Youl Lee1*, Ji Hong Cheon1, Nana Lim1, Geun Su Lee1, Youn Kyung Cho1, Sung Hoon Lee1, Hyun Kyung Lee1†

Kwangju Christian Hospital, Department of Rehabilitation Medicine1

Introduction Forty-three-year-old male patient was diagnosed with Klippel-Trénaunay syndrome and port-wine stain and Rt. spascitic hemiplegia was remarkable from his birth. He was hospitalized to our hospital because of tightness and claudication of right lower extremity which is getting worse recently. There was no abnormal findings from laboratory study and other various examination. But ABI-index was 0.96 on the left side and 1.31 on the right ABI-index by checking vascular insufficiency of lower limb and side to side difference of the lower limbs SBP was about 42. We performed infrared thermography due to the prominent temperature difference of lower legs, we could find out that the temperature of the right lower limb was 2.04 lower than that of the left. Fig.1 Klippel-Trénaunay syndrome is a rare disease which is accompanied with pathologic vascular malformation and it has distinctive characteristics that varicosities of unusual distribution, unilateral soft and skeletal tissue hypertrophy, and usually the lower extremity involved. It is usual for peripheral vascular disease patients that ischemic pain during physical activity is as a result of a mismatch between active muscle oxygen supply and demand, also the symptoms typically disappear on cessation of exercise. Methods We planned rehabilitation therapy that improves lower extremity function by increasing physical activity of affected limb. Heavy resistance training was performed by fastening 1.3kg sandbag - 4×10 repetitions at 50% of 1RM for knee extension - around right ankle and moderate-intensity aerobic exercise supplemented by resistance training at 60%-80%I-RM with 30-60 min/day of continuous aerobic exercise. In order to accurately check the daily exercise amount, the exercise amount was adjusted to about 3000 by a pedometer, and no drugs that affect the blood viscosity were used to monitor only the effect of the exercise. The aerobic exercise was continued for 2 weeks at a given time, and the clinical symptoms of the patient improved over time. Two weeks later, the F/U test was confirmed as follows. Fig.2 Conclusion The above results suggest that the reason patient's clinical symptoms were improved is the vascular supply was improved before and after the exercise, and a greater exercise amount on the right leg than the left would have had a positive influence. The reason that improved SBP difference in lower extremity might be just increase in the exercise volume, so we can think of the increased metabolites due to contracting muscle diffuse to resistance arterioles and act directly to induce vasodilation, and prolonged exercise induces angiogenesis and increases peripheral blood volume. Although the recommended mode, frequency, duration, and intensity of exercise are variable for

patient’s profile, it seems reasonable to recommend exercise as part of initial treatment strategy for individuals with peripheral vascular disease.

Fig 1. Forty-three-year-old male patient was diagnosed with Klippel-Trénaunay syndrome : port-wine stain,

unilateral soft and skeletal tissue hypertrophy and unusal varicosities

Fig 2. A) before exercise. B) after exercise : Endurance exercise training with unilateral weight lifting elicits

an average reduction of 28 mm Hg for difference of ankle SBP and average elevation of 0.5 °C for surface

temperatue of right lower extremity.

C66

Isolated Congenital Vertebral Anomalies in Torticollis Patients: Case Series

Dae-Hyun Jang1*†, Da-Ye Kim1, Dong-Woo Lee1, Jung-Ro Yoon 1

Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Department of Rehabilitation Medicine1

Introduction Because congenital muscular torticollis is the most common cause of abnormal posture of head and neck, other causes of the torticollis can be missed at the first diagnosis. Especially, vertebral anomalies are difficult to identify on physical examination or plain radiographs. Furthermore, they are likely to be overlooked, if they are not accompanying with other congenital defects such as VATER syndrome. However, there is a lack of reports about patients with isolated vertebral anomaly who have abnormal head and neck posture. Thus, we report case series of torticollis patients diagnosed with isolated vertebral anomalies. Case reports A total of 903 patients have been referred to rehabilitation department of our hospital due to abnormal head and neck posture from 2011 to 2017. Among them, eleven patients had vertebral or rib anomaly. All patients had no other defects other than bony anomaly and nine patients were diagnosed with bony anomaly before one-year old. All patients had plain x-rays taken, but only four images were confirmed as vertebral anomaly by radiologist. Six patients (54.5%) had the isolated vertebral fusion and one patient showed the isolated butterfly vertebra. Three patients (27.2%) showed multiple vertebral anomalies which are accompanied with fusion, hemi vertebra and/or butterfly vertebra. One patient had the fusion of rib only, not vertebra. Seven of 11 patients (63.6%) showed only one level bony anomaly (Table 1 and Fig. 1). Discussion According to our cases, it is not easy to rule out vertebral anomalies (especially, in case of the isolated and only one level involvement) by physical examinations and x-ray findings when evaluating abnormal head and neck posture. Therefore, if there is no abnormality in the ultrasonography of the neck, or no improvement even if the physical therapy is continued, the vertebral anomalies should be evaluated.

Table 1. Characteristics and radiologic findings of patients.

Fig 1. Cervical spine AP, lateral x-ray and 3-dimensional computed tomography

C67

Management of great auricular neuralgia confirmed by electrophysiological examination: A case report

Shin Who Park1*, Jin Seok Bae1, Yong Sung Jeong1, Hyo Sik Park1, Jong Youb Lim1, Ja Young Choi1, Kang Jae Jung1†

Eulji University Hospital and Eulji University School of Medicine, Department of Physical Medicine and Rehabilitation1

Introduction The great auricular nerve (GAN) is a sensory branch of the cervical plexus originating from the C2 and C3 nerve roots that innervates the external ear, mandibular angle, and parotid gland. [1,2,3] Idiopathic GAN neuralgia is a rare condition, and branches of the GAN overlap with other cervical and cranial nerves. Therefore, the diagnosis of GAN neuralgia is challenging and can be confused with other facial neuralgias. Here, we report the first case of GAN neuralgia confirmed by electrophysiological examination that was treated successfully with ultrasound-guided GAN block. Case report A 55-year-old female patient presented with a 12-month history of intractable pain around her left ear and mandible. She had previously undergone an ear-related examination and brain magnetic resonance imaging (MRI). There was no abnormal finding. She was diagnosed with clinical trigeminal neuralgia and started preventative medications over the span of 1 year. Despite receiving multidisciplinary medical management, the patient’s symptoms did not improve. Secondary to her persistent intractable pain, the patient was referred to our physical medicine and rehabilitation clinic for further evaluation. Given the distribution of her pain, the patient's symptoms were suspected to be not only trigeminal neuralgia but also other pathologies, including great auricular neuralgia. An electrophysiological examination was performed for the exact diagnosis. For the electrophysiological examination of the GAN, recording electrodes were placed on the back of the patient’s earlobe 2 cm apart. Stimulation was applied along the lateral border of the SCM muscle 8 cm from the active electrode.[4] And blink reflex tests were also performed. The examination revealed prolonged latency of the left GAN sensory nerve action potential and a normal range of blink reflex (Table 1). Eventually, the patient was diagnosed with incomplete lesion of the left GAN. Following the exact diagnosis of great auricular neuralgia, 2 rounds of ultrasound-guided GAN block was conducted using a local anesthetic agent and steroid (Figure 1). The patient reported immediate pain relief with a total absence of periauricular and lateral headache and symptoms did not recur. Follow-up electrophysiological examination performed 3 months later showed that the latency of the sensory action potential of the left GAN had been restored (Table 1). Discussion This is the first report of a case to confirm idiopathic GAN neuralgia by electrophysiologic study, suggesting the possibility of using electrophysiology for the diagnosis of chronic

refractory periauricular and lateral headache in patients. In conclusion, electrophysiologic studies are helpful for accurate diagnosis in patients with unclear pain in the periauricular and lateral head and to quantify the effect of interventions in GAN lesions. Further investigations are needed to ensure the reliability of the electrophysiological diagnosis of GAN neuralgia.

Fig 1. Transverse view on ultrasound depicting the right and left great auricular nerve (arrow) above the

sternocleidomastoid muscle, showing a slightly enlarged GAN on the symptomatic left side.

Table 1. Sensory nerve action potential of the great auricular nerve at the initial assessment and 3 months

following nerve block.

C68

Palmar Digital Neuropathy with Anatomical Variation of Median Nerve: Usefulness of Orthodromic Study

Jun Soo Noh1*, Hee Kyu Kwon1†

Korea University Anam Hospital, Department of Rehabilitation Medicine1

Introduction As median nerve passes under flexor retinaculum, it enlarges and divides into two portions: lateral and medial. The medial portion divides into two common palmar digital branches after passing through transverse carpal ligament. Then they each split into two proper digital nerves for the adjoining sides of 2nd to 4th digits. Selective exploration of palmar digital nerves with a nerve conduction study has long been difficult because of technical issues. In our study, we report a rare variation in the course of common palmar digital nerves of a median nerve and its neuropathy. We also describe how we figured out the neuropathy with an orthodromic sensory conduction study. Case Report A 33-year-old woman with a complaint of sensory change of a left hand visited us on August 30th, 2017. She had received a bilateral open carpal tunnel release operation on May 24th. She had felt a relief of previous symptom on thumb and index finger immediately after the surgery, but tingling sensation and hypoesthesia on left middle and ring fingers remained and got worse. On a physical examination, hypoesthesia was noted on the ulnar side of middle finger and the radial side of ring finger on a palmar side of a left hand. Also, Tinel’s sign was positive on the proximal wrist crease tapping. An electrodiagnostic study was performed on September 5th, 2017. The left median compound muscle action potential was within normal range. The left antidromic median sensory response with a middle finger recording was of low amplitude compared to the sound side. The orthodromically conducted sensory responses were unobtainable at the wrist with the ulnar side of middle finger and radial side of ring finger stimulations. The patient was then diagnosed with a complete left median sensory neuropathy of palmar digital nerve supplying ulnar side of middle finger and radial side of ring finger. Ultrasonography was performed on the same day. No abnormal findings including nerve swelling or impingement was found neither at the palm nor at the carpal tunnel. But at the distal wrist crease, compression and swelling of the median nerve were shown with fluid collection. The patient underwent a re-operation of open left carpal tunnel release on October 26th, 2017. Interestingly, a branching site of common digital nerves of the median nerve was identified not at a palm, but at a far proximal site around a distal wrist crease. In addition, a traumatic neuroma was identified on diverging site. The neuroma excision and direct end to end neurorraphy were done. After the surgery, the pain on the left middle and ring fingers was reduced by 70 percent. Discussion We report a patient with a palmar digital neuropathy with a rare anatomical variation of median nerve. Also, the usefulness of an orthodromic sensory conduction study was

clarified to eliminate the volume conducted response or co-activation of nearby nerves in the patient with selective involvement of palmar digital nerve. Table 1. Motor and Sensory Nerve Conduction Study Data

Fig. 1. Operative findings (A) The open carpal tunnel release and median nerve exploration was done on the

left side. The left median nerve (arrow) was identified, and severe tenosynovitis around flexor tendons was

found. (B) The divergence of common palmar digital nerves (arrowhead) was found around a distal wrist

crease level. A traumatic neuroma (0.5*0.5cm) (arrow) was identified on just proximal to diverging site. (C)

Neuroma excision and microscope-assisted direct the end to end neurorraphy were done.

Fig. 2. Ultrasonography (A) No abnormal finding was noted in the palm of left hand including a 3rd web

space. (B) The left median nerve was compressed at the distal wrist crease level. (C) A swelling of the left

median nerve and fluid collection around it were noted at the distal wrist crease level.

C69

A Case Report of Paraneoplastic Stiff Person Syndrome

Hyuntae Kim1*, Kyeong Eun Uhm1, Jongmin Lee1†

Konkuk University Medical Center, Department of Rehabilitation Medicine1

Introduction Stiff person syndrome, previously known as stiff man syndrome, is a progressive disorder of the central nervous system causing muscle stiffness and spasms. This uncommon entity gradually hinders one’s ambulatory function commonly leading to a disability. Its prevalence is estimated at approximately 1-2 cases per million, with only a small minority of those patients being diagnosed with the paraneoplastic variant type. Herein, we report a very rare case of paraneoplastic stiff person syndrome, secondary to sigmoid colon cancer. Case Report A 59-year-old male was presented to the department of rehabilitation with axial stiffness and truncal lurching to the right side when ambulating. These symptoms began 4 months prior to the hospital visit and had increasingly worsened as what was initially stiffness involving upper back had progressively involved lower back and proximal lower extremities. An initial physical examination revealed hyperreflexia in the upper and lower extremities with spasticity at right knee extensor muscles while ankle clonus was bilaterally equivocal. There was no previous history of neurological disorder or other relevant family history, and a electrophysiologic study exhibited no evidence of peripheral neuropathy or radiculopathy, while a lumbosacral MRI showed only disc bulging at L3-4-5-S1 levels. The patient came back two months later when there was severe limitation on spinal extension with knee extensor spasticity also being found on the left side as well. With a likely diagnosis of stiff person syndrome, diazepam was prescribed along with serum anti-GAD Ab, which later came back negative. Upon admission to the department of neurology, the patient underwent additional laboratory test of tumor markers. TFT and other tumor makers turned out to be within normal limits, but elevated CEA at 17.64. For further evaluation, both EGD and colonoscopy were performed and found a 5 cm mass was found at distal colon, which was confirmed to be sigmoid colon cancer on biopsy. Subsequently the patient underwent a surgical resection followed by chemotherapy. With continued treatment with diazepam and addition of clobazam, axial muscle stiffness has gradually improved to the point where patient was able to perform lumbar extension and truncal lurching is minimally evident. Conclusion Paraneoplastic variant of stiff person syndrome is an extremely rare and interesting disorder that presents as a progressive truncal muscle stiffness and difficulty in ambulation. Though its rarity, it should be kept in mind when making a differential diagnosis for progressive axial muscle stiffness with impaired ambulation. At the same time, consideration of the paraneoplastic variant with concurrent features of an underlying neoplasm carries a significant diagnostic value in proper evaluation and

management of such patients, as complete resolution may not occur in the paraneoplastic variant unless the cancer is properly managed.

Fig 1. Photographs of a gait sequence with truncal lurching to the right side

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iant Posterior Inferior Cerebellar Artery Aneurysm: A Rare Cause of Respiratory failure

Yunsoo Soh1†, Hee-Sang Kim1, Jong Ha Lee1, Dong Hwan Yun1, Jinmann Chon1, Yong Kim1, Jung Ho Kwon1*

Kyung Hee University Medical Center, Department of Rehabilitation Medicine1

Aneurysms of the posterior inferior cerebellar artery (PICA) are rare. The respiratory and swallowing centers are located in the brain stem near PICA. Because of its location, giant PICA aneurysm is a potential risk factor of respiratory and swallowing disorders. Surgery for these aneurysms is challenging due to the deep location and intimate relation with the medulla and cranial nerves IX, X, and XI. Although endovascular treatment of intracranial aneurysms is increasingly used as an alternative to surgery, giant PICA aneurysms were still challenging lesions, prone to procedural rupture. A 62-year-old female patient visited the department of emergency medicine due to dyspnea and choking sign when swallow. On her medial history, stress induced cardiomyopathy four years ago and intracranial giant aneurymsm were remarkable. Transthoracic echocardiograpthy(TTE) was done, but finding was unremarkable. On her Brain MRI, thrombosed PICA giant aneurym was found, and the size was 29x27x37mm. Compared to previous brain MRI, the size of aneurysm was not changed. From the analysis of arterial blood gas on 10 L/min oxygen inhalation, pH 7.31, PaCO2 75.4 mm Hg, PaO2 74.3 mm Hg, SaO2 93%, and HCO3– 37.6 mmol/L were obtained. Her mentality was changed to drowsy and intubation was done for mechanical ventilation. Under impression of increased intracranial pressure caused by giant aneurysm, decompressive occipital craniectomy was done. After the surgery her respiratory symptom was improved. After mechanical ventilation care, she transferred to rehabilitation department. She started pulmonary rehabilitation exercise for twice a day for one hour each. Respiratory muscle strengthening and stretching exercise, as well as low intensity aerobic exercise were done under saturation monitoring. After two weeks, she got pulmonary function test and result was normal findings. The Videofluoroscopic Swallowing Study (VFSS) study was done and the findings were mild penetration when liquid swallowing. Respiratory function was recoved but swallowing function still needs rehabilitation. We report a case of a 62-year-old female with giant thrombosed PICA aneurysm as clinical features of respiratory failure and swallowing disorder. We suggest that when these patients address both symptoms of dyspnea and swallowing disorder, not only surgery but pulmonary and swallowing rehabilitation is needed.

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Cosmetic prosthesis for spinal cord injured patients combined with transtibial amputation.

Tae Lim Kim1*, Hyeon Ki Hwang2, Ji Min Kim2, Jun Bong You2, Junsik Kim1, Bum Suk Lee1†

National Rehabilitation Center, Department of Rehabilitation Medicine1, National Rehabilitation Center, Department of Public Rehabilitation Service2

Introduction Lower limb amputees are conventionally prescribed with prosthesis that can both assist gait and standing position. The most commonly used type is the endo-skeletal type prosthesis. It has articulations, socket, and screw type components that are related to gait function. However, for amputees combined with motor complete spinal cord injury, gait related functions are not essential because they are unable to walk. Moreover, gait related components can cause discomfort (weight, cost, and shape) and eventually lead to low compliance. Therefore, we propose a new cosmetic prosthesis with components related to gait removed. Comparison was done between the cosmetic prosthesis and the endo-skeletal prosthesis. Method This study involved a 52-year-old T1/T3 American Spinal Injury Association Impairment Scale (AIS)-A spinal cord injury patient combined with left transtibial amputation. The underlying causes of amputation were deep vein thrombosis and atherosclerosis obliterans. The patient received an endo-skeletal prosthesis but refused to use it. The causes of refusal were heavy weight and asymmetrical appearance compared to the non-amputation side. Patient refused to show her amputated leg, hiding it with blanket even in summer and never applied it. The new cosmetic prosthesis was made to meet the following goals: (1) Durability for standing position and cycle exercise, (2) Easy to apply and light to carry, (3) Same circumference as right leg. The patient received standing position training and cycle exercise for one month with new cosmetic prosthesis applied. We compared it with the endo-skeletal prosthesis. We also measured the satisfaction of the prosthesis with Quebec user evaluation of satisfaction with assistive technology (QUEST) Version 2.0 Result In comparison between the two types, the new cosmetic prosthesis was lighter than endo-skeletal type prosthesis (0.25kg vs 1.25kg, respectively). QUEST (Version 2.0) score was higher in cosmetic prosthesis (4.5 vs 3.2, respectively). The cosmetic prosthesis was durable enough to perform standing position and cycle exercise. Conclusion For complete paraplegia patients who are unable to walk functionally and/or not willing to train gait, cosmetic prosthesis can be a feasible option. Cosmetic prosthesis is lighter, cost effective, easy to apply, and has better cosmetic appearance.

Fig 1. Novel cosmetic prosthesis

Fig 2. Cycle exercise and standing with cosmetic prosthesis applied

Table 1. Comparison between endoskeletal prosthesis and cosmetic prosthesis

C72

Paraplegia due to pyogenic spondylodiscitis of the vertebrae with a traumatic compression fracture

Yeo Hyung Kim1*, Jung Soo Lee1, Yeonji Yoo1†

Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea, Department of Rehabilitation Medicine1

Introduction Pyogenic spondylodiscitis is a bacterial infection of an intervertebral disc and its adjacent vertebrae. Although most patients with pyogenic spondylodiscitis have preceding events of invasive procedures such as epidural steroids and acupuncture, there are a few reports of primary hematogenous pyogenic infection of the intervertebral disc. We report a case of a patient who developed paraplegia as a complication of an infection of an intervertebral disc at the level of traumatic vertebral compression fracture. Case description A 54-year old woman visited the emergency room due to multiple fractures after a traffic accident. She had been diagnosed with hypertension and rheumatoid arthritis with chronic steroid therapy for several years. Computed tomography scans and x-ray images revealed mandible and zygomaticomaxillary bone fracture, right 5,6,7th rib fracture, T5 and T10 vertebral compression fracture without any neurologic deficit. She had a fever on her initial visit day and methicillin-resistant Staphylococcus aureus (MRSA) was identified in blood and sputum samples. Despite targeted antibiotics therapy, MRSA bacteremia persisted for 1 month. At 1 month after the accident, she complained of left foot drop and an electrodiagnostic study showed left lower lumbosacral radiculopathy mainly involving L5-S1 nerve root. However, at 3 months after the accident (one month after the termination of the antibiotics), she had a fever again with the recurrence of MRSA bacteremia and clinically central line-associated infection was suspected. A few days later, she complained paralysis and hypoesthesia of bilateral lower extremities. She showed muscle weakness of Medical Research Council (MRC) grade 1 in the lower extremities. A thoracolumbar spine MRI showed pyogenic spondylodiscitis at T4-5 level with unstable bursting fracture and dislocation, resulting in cord compression and cord edema. Posterolateral fusion of T2-3-4-5-6-7 level was done by an orthopedic surgeon for spinal cord decompression and correcting the kyphotic change. Conclusion Spinal cord compression can occur due to infection of the intervertebral disc and its adjacent vertebrae even after considerable time since the initial trauma. Patients who have predisposing factors such as prolonged MRSA septicemia and history of chronic steroid use can be more susceptible to hematogenous spinal infection.

Fig 1. (a) Initial spine CT (b) Spine CT after 3 months (c) Spine MR after 3 months

C73

Unusual case of Vertebral Artery Contacted Cervical Nerve Root Presenting Radiculopathy

Seung-Wook No1*, Du Hwan Kim1, Yong Min Choi1†

Keimyung University Dongsan Medical Center, Department of Rehabilitation Medicine1

Introduction Cervical radiculopathy is generally caused by spine disease such as cervical disc herniation and spinal stenosis, although vertebral artery is a rare cause of cervical radiculopathy. We report a patient presenting with radiculopathy caused by vertebral artery and treated by oral steroid. Case A 62-year-old male visited, presented with a 3-day history of left severe shoulder pain and fifth finger pain. At first, he was consulted for anethesiology department and received C4/5 interlaminar steroid epidural injection and facet block, however symptom was not improved. On physical examination, motor function was intact although tingling sensation on C7 dermatome revealed. Range of motion of the left shoulder was limited, especially in the external rotation. In addition, Neer’s test, Hawkins-Kennedy test and scarf test to be positive for left shoulder. Spurling sign was negative and cervical MRI revealed no definite compressive lesion. Ultrasonography revealed left subacromial-subdeltoid bursitis, then he received itraarticular steroid injection and suprascapular notch block. After a three-weeks of intervention, his shoulder pain was improved, however the treatment effect for fifth finger was insufficient. We performed nerve conduction study and the results of that suggested left C7 and C8 radiculopathy. (Table 1) Previous cervical MRI was not included axial image of below C6 level, additional MRI was performed. It revealed torsioned vertebral artery nearly contacted the left C7 nerve root. (Fig 1) We administrated oral steroid, after a two-weeks of administering steroids, the patient remained symptom-free. Discussion In this case, clinical presentation could be suspected as typical cervical radiculopathy. A few previous studies described the evidences of vertebral artery causes of cervical radiculopathy. We described first case of vertebral artery C7 nerve root in this case.

Fig 1. On the T2WI (A) and T2 contrast-enhanced (B) cervical MRI, left vertebral artery (VA) that were

torsioned relative to the opposite side, reaching the left C7 nerve root.

Table 1. The results of peripheral nerve conduction studies.