Objective
To investigate hypoxia-ischemia induced nigrostriatal system damages and motor behavioral changes in the immature developing rat brain. Method: For establishment of hypoxia-ischemia (HI) injury, bilateral common carotid artery occlusion was performed permanently with bipolar electrocoagulation in the postnatal day 5 rats. And then rat pups were immediately subjected to hypoxic exposure (8% oxygen) at 37^oC for 1 hour. The control group underwent sham operation and normoxic exposure. Brain injury including striatonigral system was examined. Motor behavioral changes were investigated at 2-, 4-, 6- and 8-week after HI injury using the Rota-rod test and the d-amphetamine-induced locomotor activity. Results: HI-induced motor behavioral deficits showed from 2-week to 8-week after HI injury. In the Rota-rod test, HI group exhibited significantly shorter mean fall latencies as compared to the control group. The d-amphetamine-induced locomotor activity test at the same time point showed reduced locomotor activity in HI group. HI injury resulted in brain structural damages in hippocampus, dorsolateral region of striatum and substantia nigra, and decreases in tyrosine hydroxylase-positive dopaminergic neurons in the substantia nigra. There was no evidence of spontaneous recovery in the substantia nigra at the 8-week after injury. Conclusion: HI induced brain injury at neonatal period could result in persistent motor behavioral deficits in juvenile rats. Those deficits might be linked with structural damages including nigrostriatal dopaminergic system. (J Korean Acad Rehab Med 2009; 33: 649-656)

Objective
To investigate the relationship between the transcallosal fibers (TCFs) from the corticospinal tract (CST) and the motor function of the affected extremities in patients with cerebral hemorrhage, using diffusion tensor image tractography (DTT). Method: 49 patients with cerebral hemorrhage and 38 controls were recruited. DTT was performed using 1.5 T magnetic resonance imaging. The DTT findings were classified into 3 groups according to targeting location: no TCF from the CST (type A), TCF ended in the corpus callosum or connected to the cortex of the opposite hemisphere (type B), and TCF that descending toward the lesion after passing through the corpus callosum (type C). Results: The TCF originated from the CST of the unaffected hemisphere, and the presence of fiber descending toward the lesion after passing through the corpus callosum were significantly more prevalent in the patients who showed the worse motor function. Conclusion: The TCF originated from the unaffected CST toward the lesion in patients with cerebral hemorrhage might play a relevant role in compensating motor deficits in the major corticospinal disruption. (J Korean Acad Rehab Med 2009; 33: 657-663)

Objective
To evaluate the correlation between Korean version of Berg balance scale (K-BBS) with activities related to ambulation in subjects with stroke in brain stem and cerebellum by obtaining the cutoff value for each step of K-BBS. Method: We divided the step of activities related to ambulation into 4 stages; independent sitting, independent sit to stand, independent ambulation with Q (quadripod) cane and independent ambulation without any assistance. Accordingly, we measured the K-BBS and checked the activity step in 31 subjects with stroke every other week. Data were analyzed by ROC (receiver operating characteristic) curve technique to obtain each cutoff value of the K-BBS representing individual step of activities. Results: The ROC analysis showed that each step of activity matched the following cutoff values: independent sitting, 5; independent sit to stand, 16; independent gait with Q cane, 25; and independent gait without any assistance, 35. Conclusion: K-BBS is a useful instrument in representing each step of activities related to ambulation and the cutoff values. Also, it is helpful for judging the assistance level for ambulation in subjects with stroke in brain stem and cerebellum. (J Korean Acad Rehab Med 2009; 33: 664- 667)

Objective
To evaluate the changes of gait patterns during crossing obstacles of different heights in hemiplegic stroke patients and to compare gait characteristics with those of healthy control subjects. Method: Subjects were 13 hemiplegic stroke patients and 9 age-matched healthy adults. Subjects stepped over obstacles with each height of 3, 8 and 13 cm. The three- dimensional gait analysis was performed. Temporospatial, kinematic and kinetic parameters were measured in both lead and trail limb. The pre- and post-obstacle distance, pre- and post-obstacle swing time and toe clearance were also measured. Results: With increase in height of obstacles, ratio of single limb support time, angle of hip, knee flexion in swing phase and hip extensor moment increased in both lead and trail limbs. In the lead limb, post-obstacle distance and toe clearance also increased (p＜0.05). Compared with control groups, the angle of knee flexion, hip extensor and hip flexor moment and pre- and post-obstacle distance decreased significantly in the lead limb of hemiplegic patients (p＜ 0.05). In the trail limb of hemiplegic patients, the angle of hip flexion, hip flexor moment and post-obstacle distance decreased (p＜0.05). Conclusion: Understanding strategies for adequate control and coordination of the swing limb during crossing obstacles may be the basis for the safe training of obstacle crossing in hemiplegic stroke patients. (J Korean Acad Rehab Med 2009; 33: 668-674)

Objective
To evaluate the effects of rehabilitation-start critical pathway (Rehab-CP) based on modified Rankin scale (mRS) on stroke outcomes. Method: We compared stroke outcome between before and after the carrying into effect of Rehab-CP by retrospective medical record review. First-onset stroke patients admitted to neurology department, and transferred to rehabilitation department were included in the analysis. Hospital length of stay (LOS), home discharge rate, functional outcome such as mRS, Brunnstrom stage, Korean version of modified Barthel index, Fugl-Meyer scale, mini-mental status examination, Berg Balance scale at discharge and 3 months after onset were analyzed. Results: Thirty-nine patients before the commencement of Rehab-CP and 46 patients after the Rehab-CP were compared. Length of stay in neurology department were 2.5 days shorter in after Rehab-CP group as compared to before Rehab-CP group (p=0.056) and total LOS were 1.9 days shorter in after Rehab-CP group (p=0.485), although this did not reach statistical significant difference. There were no differences in home discharge rate, and other functional outcomes between two groups (p＞0.05). Conclusion: Rehabilitation-start CP based on mRS may decrease LOS without affecting functional outcome, and this result primarily comes from the shortening of stay in neurology department before transfer to rehabilitation ward. (J Korean Acad Rehab Med 2009; 33: 675-681)

Objective
To evaluate the autonomic nervous function in post-stroke patients. Method: A total of 58 subjects, 34 post-stroke patients (mean age of 61.35 years) and 24 healthy subjects (mean age of 34.42 years) were included. The sympathetic skin response (SSR), the R-R interval variation (RRIV) and orthostatic hypotension (OH) were evaluated. Bilateral sympathetic skin responses were recorded on the palm and sole with stimulation of both median and tibial nerves. The obtained SSRs were divided into normal response and abnormal response including no response. The R-R interval variations were estimated during rest, deep breathing and Valsalva maneuver respectively. Results: In all healthy subjects, obtained SSRs were of normal response. Although the rate of abnormal SSR was 75.4% (205 of 272 waves) in stroke patients, the rate of abnormal SSR on affected side (81.6%, 111 of 136 waves) was significantly higher than unaffected side (69.1%, 94 of 136 waves) (p＜0.05). The rate of abnormal SSR according to OH was not significantly different (with OH 75.0%, without OH 75.6%) (p＞0.05). The RRIV of stroke patients with OH (1.09±0.06) was significantly lower than in control (1.14±0.05) during rest (p＜0.01), and in stroke patients without OH, the RRIV (1.13±0.06) was also significantly lower than in control (1.27±0.22) during Valsalva maneuver (p＜0.01). Conclusion: Evaluation of SSR and RRIV could be helpful in detecting dysfunction of autonomic nervous system in post-stroke patients. (J Korean Acad Rehab Med 2009; 33: 682-686)

Objective
To evaluate the usefulness of electrodiagnostic studies in hemifacial spasm patients by comparing abnormal muscle response (AMR) and irregular bursting discharge (IBD) before and after the surgery of hemifacial spasm. Method: Fifty nine patients who had been diagnosed with hemifacial spasm and underwent microvascular decompression (MVD) were chosen. The AMR was carried out in three different ways; 1) abnormal response of orbicularis oris when stimulating the supraorbital branch of trigeminal nerve (AMR1), 2) abnormal response of mentalis when stimulating the zygomatic branch of facial nerve (AMR2) and 3) abnormal response of orbicularis oculi when stimulating the marginal mandibular branch of facial nerve (AMR3). We identified the correlation between the loss of IBD and the AMR results per each method, the results of the electrodiagnostic studies according to the onset duration, and the point of follow up time. Results: The AMR and IBD decreased or disappeared after the surgery. AMR which had a significant statistical correlation with the changes of IBD, were AMR2 and AMR3. No definite changes were seen regarding the onset duration. According to the studies done during the follow up period, there was a significant reduction in lateral spread and IBD as the length of the follow up period lengthened. Conclusion: Investigation of pre- and postoperative electrodiagnostic study, especially abnormal muscle response (facio- facial reflex) is very helpful in predicting the outcome of operation and the overall prognosis. (J Korean Acad Rehab Med 2009; 33: 687-692)

Objective
To identify the thickness of gastrocnemius muscles (GCM) in normal children and children with spastic cerebral palsy using ultrasonography and to determine the influencing factors in order to increase the accuracy of intramuscular injection of botulinum toxin A. Method: Fifty-six children with spastic cerebral palsy (Group A) with no fixed contractures or operation history were involved in this study and they were compared with normal children (Group B). Children lay prone and one examiner measured the thickness of medial and lateral GCM using ultrasonography. Relationship between GCM thickness and clinical variables (age, height, weight, body mass index (BMI), calf circumference, Gross Motor Function Classification System (GMFCS) level, spasticity, number of botulinum toxin injections) were determined with Pearson's correlation. Results: The thickness of medial and lateral GCM were 78.06±14.66 mm, 66.90±12.23 mm respectively, in Group A, and 103.44±12.04 mm, 79.95±9.76 mm respectively, in Group B. Medial GCM were thicker than lateral GCM in both groups. The age, height, weight, BMI, calf circumference and the thickness of GCM were higher in Group B. In group A, weight, BMI, calf circumference showed positive correlations with the thickness of medial GCM and GMFCS showed negative correlation with the thickness of medial GCM. Conclusion: To increase the accuracy of intramuscular injection of botulinum toxin A, we should keep in mind that the thickness of GCM may be influenced by several factors. Further controlled study including larger group is needed. (J Korean Acad Rehab Med 2009; 33: 693-697)

Objective
To establish appropriate test angle of passive knee proprioception test and to compare with active knee proprioception test. Method: Thirty one healthy volunteers were tested in seated position on isokinetic machine. For passive test, the knee joints were placed in starting angle of 0^o, 30^o in flexion test and 90^o, 60^o in extension test. To memorize target angle, they were passively positioned to the target angle and left hold for 10 seconds, and returned to starting position. After these processes, knee joints were passively moved toward flexion and extension target angle. The subjects were instructed to press stop button when the memorized angles were reproduced. The tests were performed 3 times for each 6 different test angle. The active test were performed with the same memorized process but the subjects moved actively to reproduce target angles. The absolute angular errors (AAE) between target angle and produced angle were measured and compared. Results: In passive proprioception test, the AAEs were increased according to the test angle differences were increased from 30^o to 60^o. In the same target angle difference, there were no differences between starting positions. When the results of passive test were compared with active test, there were no significant differences in the flexion test, but larger angular error were measured in extension test. Conclusion: The passive knee proprioception test could be useful for patients with lower extremity weakness. Considering the possible error of large angular difference, the testing angular differences should be properly selected. (J Korean Acad Rehab Med 2009; 33: 698-703)

Objective
To evaluate the clinical validity of gugging swallowing screen (GUSS) scale in comparison with the findings of videofluoroscopic swallowing study (VFSS) for subacute and chronic stroke patients, though GUSS was developed in order to screen dysphagia in acute stroke patients. Method: The subjects of this study were thirty-five patients who had stroke for more than 3 months and were showing the symptom of dysphagia. GUSS, VFSS and clinical examination were performed respectively by three different physiatrists. These tests were performed at intervals of 24 hours or less. The result of GUSS was compared with videofluoroscopic dysphagia scale (VDS) based on VFSS, Clinical dysphagia scale (CDS), and ASHA scale based on clinical patterns. Results: The result of GUSS was in a significant correlation with VDS, CDS, and ASHA scale (p＜0.01). GUSS predicted aspiration very efficiently (area under the curve=0.928; 95% CI, 0.833 to 1.022). The cutoff value of 12 point showed sensitivity of 89.5%, specificity of 87.5%, and negative predictability of 87.5%. Conclusion: The GUSS is considered as an effective and convenient screening tool to evaluate stroke patients with dysphagia irrespective of stroke stages. (J Korean Acad Rehab Med 2009; 33: 704-710)

Vitamin B₁₂ deficiency can cause myelopathy of subacute combined degeneration of lateral and dorsal column in spinal cord. When combined with compressive myelopathy, symptoms and signs of vitamin B₁₂ deficient myelopathy could be masked. We experienced a case of forty-one year old man suffered from gait disturbance and decreased proprioception. Initially surgeons concluded his weakness resulted from myelopathy by C5-6 centrally herniated disk based on MRI and surgical decompression was performed. Gait disturbance slightly improved but decreased proprioception did not improve. Vitamin B₁₂ deficiency was found and high signal intensity lesions were found in dorsal and lateral spinal column with review of pre-op MRI. After administration with vitamin B₁₂ supplements, weakness and sensation of proprioception improved and follow-up MRI showed decreased signal intensity. We concluded the cause of his symptoms was combination of compressive myelopathy and vitamin B₁₂ deficient myelopathy. (J Korean Acad Rehab Med 2009; 33: 711-714)

Achilles tendon injuries are one of the most common tendon injuries in the lower extremities, but spontaneous bilateral achilles tendon rupture without any external force is extremely rare. We present a case of a patient who had spontaneous bilateral achilles tendon rupture related to multiple steroid injections for carpal tunnel syndrome in diabetes. According to this case, we suggest that we should take special precaution to use steroid to the diabetes though it is not applied to the achilles tendon directly. (J Korean Acad Rehab Med 2009; 33: 715-717)

Acute retropharyngeal calcific tendinitis is a rare benign condition which is characterized by acute neck pain and stiffness, and dysphagia. In this report, we present 2 cases of retropharyngeal calcific tendinitis patients. The first patient complained of neck pain and stiffness. The second patient had neck pain and hypophonia. In both cases, CT and MRI of the cervical spine demonstrated prevertebral effusion of the upper cervical spine with calcification at C1-C2 level. Acute neck pain and stiffness improved with oral administration of nonsteroidal anti-inflammatory drug. Follow-up radiologic findings revealed the disappearance of prevertebral effusion and calcification. (J Korean Acad Rehab Med 2009; 33: 718-722)

Idiopathic lumbosacral plexopathy is an uncommon idiopathic disorder characterized by acute onset of severe lower extremity pain, followed by weakness, atrophy of affected muscle, and variable sensory disturbance. A 61-year-old man experienced sudden onset of dysesthesia with weakness in right lower extremity. Electrodiagnostic study revealed patch pattern denervation at L3 and L4 root without paraspinal muscle involvement. Lumbar MRI showed abnormal signals in the right lumbar plexus. Pulse intravenous administration of high-dose immunoglobulin alleviated the sensorimotor symptoms. Abnormal signals in lumbar MRI reduced 6 months later. (J Korean Acad Rehab Med 2009; 33: 723-727)

The pathophysiology of complex regional pain syndrome is still unkown. Implantation of spinal cord stimulator is generally considered to be a safe and effective procedure. The reported complications are generally minor without serious neurologic deficit. A 21-year-old male patient with CRPS in the right foot had undergone spinal cord stimulator implantation. After the surgery, spinal epidural hemorrhage occurred and he became paraplegic. After spinal cord injury, symptoms of CRPS disappeared. This supports the hypothesis of spinal neuronal sensitization. This case would help to understand pathophysiology of CRPS development. (J Korean Acad Rehab Med 2009; 33: 728-730)

Congenital muscular torticollis (CMT) is the most common cause of abnormal posture of the head and neck in infancy. Familial transmission of CMT has not been reported in Korean literature, to our knowledge. Four cases with CMT found in siblings are presented in this paper along with the review of literature on hereditary factor as one of the possible mechanisms on pathogenesis of CMT. Further case reports are required in order to verify heredity as a possible pathogenetic factor of CMT. (J Korean Acad Rehab Med 2009; 33: 731-734)

Duchenne muscular dystrophy (DMD) is a severe X-linked recessive disorder characterized by rapid progression of muscle wasting and weakness. Long term noninvasive intermittent positive pressure ventilation (NIPPV) is an important treatment for neuromuscular patients with chronic respiratory failure. NIPPV is easy to administer and life-threatening complications are rare. We report two cases of pneumothorax associated with long term NIPPV in DMD. Given the increasing utilization of chronic NIPPV, we suggest that caregivers and patients must be aware of this potentially life-threatening complication. (J Korean Acad Rehab Med 2009; 33: 735-738)

Superior mesenteric artery syndrome (SMAS) is a rare cause of proximal duodenal obstruction resulting from compression of the duodenum by the SMA against the aorta. Risk factors associated with SMAS are prolonged supine position, weight loss and decreased abdominal wall muscle tone; all of which are frequently accompanied with traumatic brain injury (TBI). The following case report describes a patient who developed SMAS in the setting of TBI. This report presents a 16 year old male with TBI who had postprandial epigastric pain, vomiting and weight loss. Computed tomography and upper gastrointestinal series demonstrated the existence of SMAS. The patient was managed conservatively with total parenteral nutrition to obtain a positive nitrogen balance. Physician should consider SMAS in the differential diagnosis of patients presenting with abdominal pain and vomiting. (J Korean Acad Rehab Med 2009; 33: 739-741)

A subset of aged individuals with Down syndrome (DS) exhibits eating, drinking, and swallowing (EDS) difficulties, which have the potential to lead to life-threatening conditions such as malnutrition. We report a case of 37-year-old woman with DS, who developed Wernicke's encephalopathy related to malnutrition that was caused by EDS problems. The patient presented with a history of EDS problems for 2 years without treatment and had developed mental-status changes, unsteadiness of stance and gait with associated MRI findings, corresponding to Wernicke's encephalopathy. The patient was treated with nutritional support including thiamine replacement and dysphagia rehabilitation therapy. Our case highlights the importance of early and proper management of malnutrition associated with EDS problems in adult DS. The suspicion of Wernicke's encephalopathy must be considered when adult DS manifests as prolonged malnutrition, altered mentality and decreased mobility. (J Korean Acad Rehab Med 2009; 33: 742-745)