Objective
To investigate therapeutic effects of anodal direct current (DC) polarization on the primary motor cortex in subacute and chronic stroke patients by measuring changes of hand function and corticospinal excitability before and after stimulation. Method: Fourteen subacute and chronic stroke patients were included in this study. This study was designed as a sham-controlled, double-blind, and crossover experiment. The anode was positioned on the primary motor cortex of the affected hemisphere. The primary motor cortex was identified using transcranial magnetic stimulation (TMS), the motor evoked potentials (MEPs) were recorded by surface electrodes placed over the contralateral first dorsal interosseous muscle. DC was delivered for 20 minute at 2 mA with 25 cm² saline-soaked sponge electrodes. Before and after DC polarization, we checked the box and block test, nine hole peg test, grip power, lateral prehension power, MEPs amplitude, and MEPs latency. Results: The box and block test, grip power, lateral prehension power, and MEPs amplitude increased after anodal DC to primary motor cortex (p＜0.05). Positive correlation showed between improvement of box and block test and change of MEPs amplitude (r=0.808, p=0.001). Conclusion: Increased hand functions and the corticospinal tract excitability were obtained by 2 mA, 20 minute anodal DC polarization. Anodal DC polarization to primary motor cortex may play a potential role for facilitating the corticospinal tract thereby enhancing hand motor recovery in stroke patients. (J Korean Acad Rehab Med 2009; 33: 259-264)

Objective
To determine the effectiveness of electrical stimulation over the trunk in improving trunk control during early stroke rehabilitation. Method: Thirty-two acute and subacute hemiparetic stroke patients were enrolled in this study. All patients were randomly assigned to one of two groups, control group or electrical stimulation (ES) group. Both groups received the same physical therapy for 3 weeks. ES group received additional electrical stimulation over the posterior back muscles for 30 minutes a day, 5 days per week for 3 weeks. Outcome measurements included Korean version of Berg balance scale (K-BBS), total score of postural assessment scale for stroke patients (PASS), trunk control subscale of postural assessment scale for stroke patients (PASS-TC), trunk control test (TCT), Korean version of modified Barthel index (K-MBI), and motricity index (MI). These measurements were checked before and after treatment. Results: There were no significant differences in the baseline characteristics and initial values between two groups. Following 3 weeks therapy, the changes of TCT and PASS-TC scores in the ES group were significantly higher than those of the control group (p＜0.05). The changes of K-BBS, PASS, and K-MBI scores in the ES group tend to be higher than those in the control group. However the differences were not statistically significant. The changes of PASS-TC and TCT scores were significantly correlated with the changes of BBS and K-MBI scores at discharge. Conclusion: This study suggests that electrical stimulation over the trunk may be a beneficial therapeutic technique in improving trunk control in acute and subacute hemiparetic stroke patients. (J Korean Acad Rehab Med 2009; 33: 265-270)

Objective
To investigate the effect of driving-simulator based training for the persons with brain injury. Method: Twenty-seven brain injury patients and 19 healthy volunteers were included in this study. Driving simulator program was composed of an aptitude test (which have 4 items) and simulated road driving. The brain injury patients had 4 sessions of driving simulator training with assessment performed during the first and the last session. Healthy volunteers underwent only one driving simulator session for assessment. To evaluate subjective satisfaction in terms of training effect and the sense for the real, a survey was administered after the training. Results: In brain injury patients, there were significant improvements in both aptitude test and simulated road driving test after training (p＜0.01). There were no significant differences between the scores of patients taken at the last session and the scores of healthy volunteers, while the scores of patients taken at the first session were significantly lower than those of healthy volunteers. The patients group reported positively in terms of training effect (81.5%) and the sense for the real (62.9%). Conclusion: A driving-simulator based training was effective for brain injury patients to regain driving skill. (J Korean Acad Rehab Med 2009; 33: 271-275)

Objective
To investigate the changes of causes, clinical features, and functional outcomes in childhood strokes. Method: This study included 152 patients, aged from 1 to 18 years, who were diagnosed with stroke and admitted to a tertiary hospital between January 2000 and April 2004. All medical records and neurologic images of the patients were reviewed. A parental questionnaire was used to investigate patients' functional outcomes. These results were compared with those of the previous study performed in the same hospital in 2001. Results: The number of hemorrhagic stroke was 78 (51.3%) and that of ischemic stroke was 74 (48.7%). When compared to the previous study, the incidence of hemorrhagic stroke especially above the age of 10 years decreased and that of ischemic stroke below the age of 10 years increased. The causes of stroke were arteriovenous malformation (AVM, 42.8%), Moyamoya disease (37.5%), vasculitis (5.3%), cardiac disease (3.9%), hematologic disease (2.0%), and undetermined (8.5%). Common clinical features were headache (53.8%), vomiting (43.6%) and loss of consciousness (28.2%) in the hemorrhagic stroke, and hemiparesis (94.6%), headache (35.1%) and speech disorder (31.1%) in the ischemic stroke. 86.0% of the hemorrhagic and 64.8% of the ischemic stroke patients were categorized in the 'good' outcome group. Conclusion: The incidence of ischemic stroke increased to the similar level of hemorrhagic stroke. The most common causes were AVM in the hemorrhagic and Moyamoya disease in the ischemic stroke. Most of these patients showed good functional outcome, regardless of the causes of stroke. (J Korean Acad Rehab Med 2009; 33: 276-281)

Objective
To evaluate the reorganization of descending motor pathways of trunk muscles in stroke patients. Method: Nine patients with unilateral hemispheric stroke were enrolled. Their mean age was 56 years. Transcranial magnetic stimulation (TMS) was applied to unaffected and affected motor cortices in turn and bilateral electromyographic recordings were made from rectus abdominis, external oblique abdominal, and 4 th and 9 th thoracic erector spinae muscles during resting. The onset latency and peak-to-peak amplitude of motor evoked potential (MEP) were measured for each muscle on both sides. Results: Stimulation of the unaffected hemisphere evoked contralateral responses in all patients. Ipsilateral responses were more common in TMS of affected hemisphere. Ipsilateral but not contralateral MEPs were obtained in TMS of affected hemisphere. Conclusion: These results demonstrated that the variable availability of bilateral crossed and uncrossed corticomotorneuronal projections among patients could be related with the inconstant occurrence of trunk weakness after unilateral hemispheric stroke. (J Korean Acad Rehab Med 2009; 33: 282-289)

Objective
To determine the intensity of aerobic exercise in stroke patients using heart rate reserve (HRR) by comparing maximal oxygen consumption (VO_2max) and VO₂ at % HRR in maximal exercise test of treadmill, arm ergometer and bicycle ergometer. Method: Twenty nine stroke patients who could walk independently were included. Maximal exercise test using treadmill, arm ergometer and bicycle ergometer was performed. Heart rate, rating of perceived exertion, minute ventilation, oxygen consumption and respiratory exchange ratio were measured through respiratory gas analysis. When the standard criteria for maximal oxygen consumption (VO_2max) was achieved, each test was terminated. We compared the measured VO_2max with the VO₂ at % heart rate reserve (HRR) and figured out the statistically significant % HRR point. Results: Twenty-four (82.7%), twenty-four (82.7%) and twenty-five (86.2%) patients completed maximal exercise test using treadmill, arm ergometer and bicycle ergometer. Most patients who completed maximal exercise test satisfied the VO_2max criteria with VO₂ plateau at the end of the exercise test (41.3∼48.2%) or RER＞1.0 (79.3∼82.7%) or peak HR＞age-predicted maximal heart rate (APMHR)-10 or peak HR＞70% {208−(0.7×age)} when they took Ղ- blockers (6.8∼13.7%). The differences between measured VO_2max and VO₂ above 60% HRR at treadmill test, 65% HRR at arm ergometer test, 65% HRR at bicycle ergometer test were not statistically significant (p＞0.05). Conclusion: Exercise above 60% HRR at treadmill test, 65% HRR at arm and bicycle ergometer test can be useful as aerobic exercise intensity in stroke patients. (J Korean Acad Rehab Med 2009; 33: 290-296)

Objective
To investigate the clinical effect of stellate ganglion block in patients with secondary lymphedema after breast cancer treatment. Method: In a prospective clinical trial, the consecutive stellate ganglion block (SGB) was performed every two weeks to 10 patients (Mean age 46.0±9.4 (yr)) who was diagnosed as of secondary lymphedema after breast cancer treatment. The parameters were the circumstance of arm and the thickness of skin and subcutaneous tissue of the affected arm measured by ultrasonography. We measured these parameters with baseline value before SGB treatment and repeated the evaluation after each SGB treatment. And the subjective data of satisfaction, softness and improvement were obtained by questionnaires. Results: 10 patients were treated with stellate ganglion block. The mean circumferences of upper arm and forearm after three consecutive SGB treatments reduced significantly: upper arm from 31.39 cm to 29.72, forearm from 25.14 cm to 23.64 cm (p＜0.05). And the thickness of subcutaneous tissue of upper arm significantly decreased under no- compression measuring technique after three SGB treatments (p＜0.05). The compliance of superficial tissue showed significant change with serial procedure. Almost all of the patients had a satisfaction and feeling of softness in their affected arm after treatments. Conclusion: The cervical stellate-ganglion block reduced the circumstance and the thickness of arm with lymphedema and satisfied almost lymphedema patients. So this treatment presents a favorable outcome to the breast cancer-related lymphedema patient clinically. (J Korean Acad Rehab Med 2009; 33: 297-303)

Objective
To investigate the expression of cytokines and growth factors in disc specimens obtained from small numbers of patients with herniated nucleus pulposus (HNP) and degenerated disc disease (DDD). Method: A total of ten human intervertebral disc samples consisted of five painful degenerative discs and five herniated intervertebal discs were obtained from surgery. MRI and Western blot analyses on these disc samples were performed to determine the levels of disc degeneration and the expression levels of cytokines and growth factors. Results: The levels of IL-6 were significantly greater in the DDD patients than in the HNP patients, but no statistical differences were observed in the expression of IL-1Ղ, IL-8 and TNF-Ձ between the HNP and DDD patients. In addition, the expression of TGF Ղ was significantly higher in the DDD patients than in the HNP patients. Conclusion: The higher levels of cytokine and growth factor expression in the DDD than in the HNP show why discogenic patients usually have more severe back pain than patients with herniated discs. (J Korean Acad Rehab Med 2009; 33: 304-308)

Objective
To find the correlation between dorsal root ganglion location and abnormal superficial peroneal sensory nerve action potential (SNAP) response in L5 radiculopathy. Method: This retrospective study included thirty-three patients with unilateral L5 radiculopathy, who had no peripheral polyneuropathy, focal neuropathy or other metabolic disease and were under 60 years. 33 patients were classified to two groups: group I with an abnormal superficial peroneal SNAP response and group II with a normal superficial peroneal SNAP response. Using axial view of MRI, the location of dorsal root ganglion (DRG) of the study group was classified into intraspinal, intraforaminal and extraforaminal space. Results: In group I, 71% of L4 dorsal root ganglion was located in intraforaminal space, and 14% in extraforaminal space and 64% of L5 DRG was in intraforaminal space and 14% in intraspinal. In Group II, 42% of L4 DRG was located in intraforaminal space, and 58% in extraforaminal and 26% of L5 DRG in intraforaminal space and 63% in extraforaminal space. Group I subjects were more located in the intraforaminal space than Group II subjects (p＜0.05). Conclusion: In spite of belief that "radiculopathy involves the nerve root proximal to DRG", the significant proportion of dorsal root ganglion was located inside intraforaminal space. Thus the intraspinal lesion such as disc protrusion or spondylotic encroachment may compress DRG and cause abnormal findings of SNAP in EMG study. (J Korean Acad Rehab Med 2009; 33: 309-315)

Objective
To investigate the relationship between respiratory muscle strength and cardiac function in patients with Duchenne muscular dystrophy (DMD). Method: This study included 37 patients with DMD. Cardiac function of patients was evaluated by thoracic echocardiography, which recorded left ventricular ejection fraction (LVEF). Maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP) representing respiratory muscle strength and blood sampling for brain natriuretic peptide (BNP) were performed. Results: LVEF did not show significant correlation with MIP, MEP or age. However, LVEF was negatively correlated with BNP level. Conclusion: Cardiac dysfunction of patients with DMD didn't correlate with age or respiratory muscle strength. Therefore, investigation of cardiac function itself is needed for patients with DMD irrespective of respiratory compromises. (J Korean Acad Rehab Med 2009; 33: 316- 320)

Objective
To investigate the relationship among the alcohol drinking history, autonomic symptom scores (ASS), and the autonomic functions measured with sympathetic skin response (SSR) and heart rate variability (HRV) of alcoholic patients, and to assess the difference between the values from the autonomic function tests of patients and normal controls. Method: SSR and HRV were measured in 44 patients and 26 controls. ASS and Toronto clinical neuropathy scoring system (TCNSS) scores were also assessed. For the HRV, the mean heart rate, standard deviation of the NN intervals (SDNN), total power (TP), very low frequency (VLF), low frequency (LF), and high frequency (HF) in both the supine and standing positions were evaluated. For the SSR, the onset latency and amplitude of both the palm and sole were measured. Results: There were no significant relationships among the alcohol history, the TCNSS, and the results of the autonomic function tests. There were, however, significant relationships among their ASS and some values from autonomic function tests [i.e., the sole amplitudes, the SDNNs (supine), and the TPs (standing)]. There were significant differences between the sole amplitudes of the patients and controls. In HRV, there were significant differences between the patients and controls with respect to their SDNNs and TPs at a standing position. Conclusion: Autonomic function tests such as SSR and HRV are related to ASS, but not to alcohol history and TCNSS. Moreover, the values from the autonomic function tests of the alcoholic patients decreased, unlike the normal controls. (J Korean Acad Rehab Med 2009; 33: 321-326)

Objective
To estimate the health-related quality of life (HRQOL) in patients who were referred for a disability assessment and identify the factors affecting their HRQOL. Method: The referral group was consisted of 117 patients who visited the rehabilitation outpatient clinic for an assessment of the disability. The non-referral group was consisted of 468 patients who visited for being treated for an illness. The control group was consisted of 410 healthy adults who had no illness. Subjects were interviewed using the questionnaire including age, sex, educational level, marital status, employment status and monthly income. The HRQOL of all subjects was measured by the Korean version of the medical outcome study 36-item short-form health survey (KSF-36). The correlation between KSF-36 score and all variables was analyzed and KSF-36 score of each group was compared with those of others. In the referral group, KSF-36 score was analyzed by all variables. Results: The physical and mental component summary in the referral group were significantly lower than other groups. In the referral group, there were moderate positive correlations between monthly income and all KSF-36 scores, between employment status and physical component scores. And also there was a significant difference of almost all of component scores according to employment status and monthly income. Conclusion: The HRQOL of the referral group was significantly lower than those of non-referral and normal control groups. The social factors like employment status and monthly income would be affecting factors on HRQOL of the referral group. (J Korean Acad Rehab Med 2009; 33: 327-332)

Objective
To evaluate the effect of extracorporeal shock wave therapy (ESWT) in plantar fasciitis with visual analog scale score and thickness of fascia by ultrasonography. Method: The subjects consisted of 32 feet (24 patients) with established diagnosis of chronic plantar fasciitis, including 17 feet in the ESWT group and 15 feet in the control group. In the ESWT group, three session of ESWT (0.24 mJ/mm² FED, 1,200 impulse, weekly) were performed. The visual analog scale (VAS) score and thickness of the plantar fascia were measured by ultrasound before therapy and at the 6-week and 6-month follow-up. Patients in the control group were treated with medication, orthotics, physical therapy and exercise program. VAS and thickness of plantar fascia was evaluated at the same time as ESWT group. Results: In the ESWT group, thickness of plantar fascia decreased significantly at 6-week follow-up (p＜0.05) and 6-month follow-up (p＜0.05). Control group showed no significant difference at follow-up (p＞0.05). Visual analog scale score showed no significantly difference at 6-week follow-up (p＞0.05), but decreased at 6-month follow-up. On the other hand, in the control group, thickness of plantar fascia did not change significantly at 6-week follow-up (p＞0.05) and 6-month follow-up (p＞0.05). VAS score was not significant different at the 6-week follow-up (p＞0.05), but decreased at the 6-month follow-up (p＜0.05). Conclusion: ESWT in plantar fasciitis is effective in relieving subjective pain and reducing thickness of plantar fascia at 6-month follow-up. (J Korean Acad Rehab Med 2009; 33: 333-338)

Objective
To compare the effects of cardiac rehabilitation between patients with ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). Method: Thirty three patients with STEMI or NSTEMI who underwent percutaneous transluminal coronary angioplasty were recruited. All patients participated in cardiac rehabilitation program including ECG monitoring exercise for 6 weeks. Several parameters such as exercise duration, oxygen consumption, heart rate, blood pressure and rate pressure product were evaluated through graded exercise test before and 6 months after initiation of cardiac rehabilitation program. Results: After cardiac rehabilitation program, the STEMI group showed significant changes in exercise time, maximum oxygen consumption, resting heart rate and submaximal rate pressure product. The NSTEMI group also showed significant improvement of exercise time, maximum oxygen consumption and submaximal rate pressure product. There was no significant difference in the changing rate between two groups. Conclusion: Both the STEMI and the NSTEMI groups showed similar improvement of cardiopulmonary exercise capacity 6 months after cardiac rehabilitation program. (J Korean Acad Rehab Med 2009; 33: 339-343)

Objective
To verify proper stimulation point of ulnar nerve at the wrist by investigating anatomical relation of ulnar nerve and flexor carpi ulnaris (FCU) muscle. Method: Cadaver dissection of 9 wrists was done to identify gross anatomical relation of ulnar nerve and FCU muscle. Ultrasonography of 17 healthy volunteers was done for the measurement of distance from lateral border of FCU muscle to ulnar nerve at three sites. Ratios of these distances to total width of FCU muscle and FCU tendon were calculated. Results: FCU muscle was composed of lateral tendinous and medial muscular portion, and all ulnar nerves were located under the tendinous portion of FCU muscle on cadaver dissection. Ultrasonographic distances from lateral border of FCU muscle to ulnar nerve were 4.6±3.3 mm, 4.8±4.0 mm and 5.9±3.1 mm from distal to proximal sites. The ratios to total width of FCU muscle were 31.02± 23.31%, 24.30±26.12% and 24.48±13.01%, which showed that the ulnar nerve was closer to the lateral border than the medial border. The ratios to total width of FCU tendon were 49.63±41.35%, 51.30±50.46% and 64.59±36.79%, which showed progressive increment from distal to proximal sites. Conclusion: Proper stimulation point of ulnar nerve at the wrist is the lateral border of FCU muscle than the medial border. However, the proximity of ulnar nerve to the medial or lateral border was not conclusive, because the ratio to FCU tendon was not consistent in three sites of the wrist. Further electrophysiologic study is necessary for the comparison of proper stimulation point based on FCU tendon. (J Korean Acad Rehab Med 2009; 33: 344-347)

Objective
To describe the findings of videofluoroscopic study (VFSS) and investigate the usefulness of VFSS as a predictor of aspiration pneumonia in infants with aspiration symptoms. Method: Thirty-eight infants with aspiration symptoms were divided into two groups: those who showed aspiration symptom but had no pneumonia (Aspiration group); those with episode of aspiration pneumonia (Pneumonia group). The subjects' medical records and the results of VFSS were reviewed. Results: In aspiration group, oral phase was normal and the abnormalities were found only in pharygeal phase in a small number of subjects. On the other hand, pneumonia groups showed poor lip closure and bolus formation in oral phase. Abnormalities of pharyngeal phase were reduced laryngeal elevation, coating of pharyngeal wall, increased residue of valleculae, and delay of pharyngeal transit time. Penetration and aspiration were more frequently observed (p＜0.05). Aspiration pneumonia occurred more frequently among infants who had supraglottic penetration (p＜0.05). Conclusion: Mild abnormalities were found only in pharyngeal phase in aspiration group, whereas VFSS abnormalities were observed in both oral and pharyngeal phase in infants with pneumonia. Our results suggest that VFSS would be useful in predicting the development of pneumonia in infants with aspiration symptoms. (J Korean Acad Rehab Med 2009; 33: 348-352)

The traditional treatment of piriformis syndrome includes heat modality, deep muscle massage, slow stretch exercise, injection of local anesthetics, and surgical division of piriformis muscles in some selected cases. More recently, the use of botulinum toxin (BTX) for the treatment of piriformis syndrome has been suggested. We experienced two cases of piriformis syndrome with distinctive clinical feature. The symptoms of these two cases were not controlled by conservative managements including physical therapy, direct injection of lidocaine or steroid, or caudal block. So we injected Type A BTX in the piriformis muscle with the guidance of CT scan. 8 weeks after the botulinum injection, symptoms had almost completely disappeared, and follow up CT scan showed sufficient atrophy of piriformis muscles. The CT guided BTX injection in the piriformis muscle might emerge as a feasible technique to obtain a good local therapeutic effect without risk of imprecise inoculation. (J Korean Acad Rehab Med 2009; 33: 353- 356)

Patients with conversion disorder are often presented with critical symptoms or signs which could suggest severe organic disorders. Hysterical hemiparesis is a relatively rare presentation and it is difficult to diagnose because it is displayed as a unilateral motor weakness with or without sensory deficits. A previously healthy 23-years-old woman developed sudden onset of hemiplegia and hemianesthesia with loss of anal tone. Before the onset, she had a traffic accident. A through medical workup including X-rays, MRI, CT scans, EMG, and brain SPECT revealed no organic causes for such neurologic deficits. She gradually regained neurologic function over 2 months from the onset. Conversion disorder should be considered when symptom- related anatomic or physiologic abnormalities could not be proven with appropriate workup. Medical evaluation must be performed in advance to the diagnosis of conversion disorder to avoid misdiagnosis. (J Korean Acad Rehab Med 2009; 33: 357-360)

Hemiplegic stroke patients may have abnormal awareness or perception of the affected limb (s). For example, patients may experience their limb as not belonging to them (asomatognosia) or attribute their own body parts to other persons (somatoparaphrenia). Disturbed sensation of limb ownership (asomatognosia, somatoparaphrenia) for the hemiplegic limb has been reported in patients with right insula lesion. We report a case of a 70-year-old right handed female who had somatoparaphrenia and neglect dyslexia after right posterior cerebral artery and posterior corpus callosal infarction. Additionally, she showed visual defect, dyschromatopsia, and hemispatial neglect. (J Korean Acad Rehab Med 2009; 33: 361-364)

Peduncular hallucinosis that rarely reported in patients with brain stem lesion has several characteristics. The hallucination tends to be vivid, nonstereotypical images of person or animal. All the patients are aware that the hallucination is not part of reality. One of the suggested mechanisms of peduncular hallucinosis is imbalance among the cholinergic, serotonergic and other transmitting systems in the brain stem. We report two cases with typical features of peduncular hallucinosis which appeared about 30 and 12 months after pontine hemorrhage, respectively. We chose antipsychotics and selective serotonergic reuptake inhibitors for their medications, and their hallucinations disappeared about 2 months and 3 weeks after the medication, respectively. We suggest that peduncular hallucinosis should be considered in the patients with pontine hemorrhage if they complain of typical visual hallucinations. (J Korean Acad Rehab Med 2009; 33: 365-368)

There have been few reports on a pharyngoesophageal diverticulum in dermatomyositis patients. This report concerns a young woman suffered from dermatomyositis, and resulting in dysphagia. Although dysphagia is a common manifestation of inflammatory myopathy, it was associated with a pharyngoesophageal (Zenker's) diverticulum in this case. The videoflouroscopic study showed a diverticulum of the pharyngoesophageal junction. Esophagography confirmed a complicated Zenker's diverticulum that was a tubular mucosal pouch with poor distensibility and mucosal irregularity on left posterolateral aspect of the pharyngoesophageal junction. After 4 months, dysphagia improved and pharyngoesophageal diverticulum disappeared on esophagography and neck computed tomography. To our knowledge, there has been no report of a pharyngoesophageal diverticulum in a dermatomyositis patient with dysphagia in Korea. We report clinical and laboratory findings of our case and review association with a pharyngoesophageal diverticulum and dermatomyositis. (J Korean Acad Rehab Med 2009; 33: 369-372)