Objective
To investigate the effect of environmental enrichment on the cognitive and motor development in the experimental hypoxia-ischemic encephalopathy neonatal rat model. Method: Hypoxic-ischemic encephalopathy models were made in neonatal Sprague-Dawley rats at 3 days of age by ligating the unilateral carotid artery followed by inhalation of 8% oxygen and raised in the enriched environment (n=10), treadmill exercise (n=8) and non-stimulation (n=10) from the 3rd to 8th weeks of age. Neurobehavioral and histopathological changes were compared. Results: The neurobehavioral tests of the rats with hypoxic- ischemic encephalopathy showed prolonged latencies of achievement for cliff avoidance and negative geotaxis (p＜0.05). Persisting abnormality into adult life of limb placing improved in exercise and enriched environment groups and spatial learning and memory in a water maze recovered in the rats with enriched environment (p＜0.05). The density of dendritic spine increased in the hippocampus with enriched environment (p＜0.05). Conclusion: The present study supports the possibilities of the positive effects after the enriched environment in the developing brain with hypoxic injury. (J Korean Acad Rehab Med 2010; 34: 1-9)

Objective
To investigate whether transcranial direct current stimulation (tDCS) can improve dysarthria in stroke patients. Method: Twelve patients who developed dysarthria after acute middle cerebral artery (MCA) infarction were included in this study. In a prospective, double blinded, randomized case control study performed between January 2007 and December 2008, six patients were randomized to anodal tDCS application and conventional speech therapy, and six patients were randomized to the sham group which received only conventional speech therapy. tDCS was delivered for 30 minutes at 2 mA with 25cm², five times/week, for a total two weeks. The effects were assessed in maximal phonation time (MPT), alternative motion rates (AMR)-Pa, AMR-Ta, AMR-Ka, and sequential motion rates (SMR)-PaTaKa using the Multi-Media Dimension Voice Program. Results: Pre-treatment patient evaluation showed no significant difference between the two groups for all parameters. The MPT, AMR-Pa, AMR-Ta, AMR-Ka, and SMR-PaTaKa were improved pre- and post-treatment in the stimulation group, while MPT, SMR-PaTaKa were improved in the sham group (p＜0.05). The AMR-Pa significantly improved in the stimulation group compared to the sham group (p＜0.05). Conclusion: As these results demonstrated the beneficial effects of anodal tDCS on dysarthria, tDCS can successfully be used as a treatment modality for patients suffering from dysarthria after stroke. (J Korean Acad Rehab Med 2010; 34: 10-14)

Objective
To investigate the incidence of vocal cord palsy (VCP) in acute ischemic stroke patients and its influence on aspiration risk. Method: Fifty patients with first-ever acute stroke were enrolled. The mean age was 68.3 years and there were 21 men and 29 women. Based on clinical and neuroimaging findings, their stroke subtype was categorized into cortical/ subcortical (Group A), lateral medulla (Group B) and other brainstem (Group C). We examined them by using flexible fiberoptic rhinolaryngoscope and videofluroscopic swallowing study (VFSS) within 2 weeks after stroke onset. The Penetration - Aspiration Scale (PAS) was used to score each VFSS. Results: Among the 50 patients, VCP was found in 15 (30%): 15.8% of group A, 100% of group B and 40% of group C. VCP was contralateral to the brain lesion in group A and ipsilateral in 85.7% of group B. Aspiration risk was found in 38% of the all patients and 53% of VCP had aspiration risk. No differences in the incidence of aspiration risk were noted according to VCP (՗²=2.138, p=0.144). Conclusion: There was no relationship between VCP and aspiration risk in acute ischemic stroke patients. Although VCP is a known risk factor for aspiration, other factors are important in determining an effective swallowing. (J Korean Acad Rehab Med 2010; 34: 15-19)

Objective
To compare differences in postural changes during dual-task performance (DTP) between stroke patients and healthy controls, and to investigate the relationship between postural control and attention during DTP in stroke patients. Method: Twenty-nine subacute stroke patients who were able to stand independently and ten age-matched, healthy controls were enrolled in the study. The postural control of subjects was evaluated in all of the following four conditions using posturography: a simple standing state with eyes open (EO), a DTP with EO, a simple standing state with eyes closed (EC) and a DTP with EC. The dual-task was performed by standing while inversely repeating a given four-digit number. The parameters were stability index (SI) and weight distribution index (WDI) in posturography. Both visual and auditory inattention of the stroke patients were measured using the computer neuropsychologic test. Results: In stroke patients, SI and WDI increased significantly during DTP (p＜0.05) both their EO and EC status. The change of SI during DTP was positively correlated with the visual and auditory inattention in stroke patients (p＜0.01) with their EO status. No significant correlations were noticed in WDI. Conclusion: Postural changes during DTP increased more in stroke patients than in healthy controls. Postural control showed a significant correlation with visual and auditory attention during the DTP in stroke patients. We therefore expect that dual-task training using postural control and attention will be an attractive treatment method for increasing postural stability in stroke patients. (J Korean Acad Rehab Med 2010; 34: 20-26)

Objective
To measure knee joint proprioception quantitatively in hemiplegic patients after brain injury using an isokinetic dynamometer. Method: Thirty healthy subjects and 24 hemiplegic patients participated in this study. Joint position sense was evaluated with passive angle reproduction of 30^o and 60^o of knee flexion and kinesthesia was evaluated with the threshold for detection of passive movementfrom 45^o of knee flexion. We used toe-"up or down"-test for conventional clinical method. Results: Significant proprioceptive deficit was observed not only in paretic knees of both right and left hemiplegic patients (p＜0.05) but also in nonparetic knee in right hemiplegic patients (p＜0.05). Both interrater and intrarater reliability of the quantitative measurement were significantly high. A significant difference was found between proprioception deficit defined with current clinical test and quantitative test in the nonparetic knee (p＜0.05), but not in the paretic knee (p＞0.05). Conclusion: The quantitative test using an isokinetic dynamometer is a reliable method to measure knee proprioception, and it is possible to detect proprioceptive deficit in hemiplegic patients. Conventional clinical assessments are poor for predicting the results of the quantitative measure in the nonparetic knee. This quantitative method may be useful in diagnosis and follow-up of knee proprioception of hemiplegic patients after brain injury. (J Korean Acad Rehab Med 2010; 34: 27-33)

Objective
To find out the actual state of smoking, which is one of major risk factors of cardiovascular diseases after spinal cord injury (SCI), of community-dwelling persons with SCI, and the differences of smoking behaviors from general populations. Method: The persons with SCI living in community drew up a self-report paper-based questionnaires which were made up based on The third Korea National Health and Nutrition Examination Survey questionnaires for data comparisons. Demographic data, smoking duration, amount, cessation attempt and plan were asked. Results: Questionnaires were sent to 459 persons with SCI and 332 persons from twenties to sixties were finally analysed. In men, the lifetime smoking rates of SCI subjects in their forties and fifties were lower and the current smoking rate of tetraplegic subjects in their forties and fifties were lower than those of general population. But the amount of smoking and attempt to stop smoking were of no differences. In women, there were no significant differences in all parameters. Conclusion: There were no significant differences in smoking rates and amounts between SCI patients and general populations, but smokers with SCI showed weak intention to cease smoking. (J Korean Acad Rehab Med 2010; 34: 34-40)

Objective
To investigate the transfer activities in patients with spinal cord injury (SCI) after discharge, and assess the caregivers' pain related to patient transfer in the community residence. Method: One hundred seventeen SCI patient and 35 caregivers for the patients dependent on bed-wheelchair transfer activities were included. As for SCI patients, motor index score (MIS), one transfer item from the Korean version of modified Barthel index (K-MBI), and three items related to transfers from the spinal cord independence measure (SCIM) II were evaluated. Regarding caregivers, musculoskeletal pain with patient transfer, ease-of-use and safety of transfer methods including an electric-powered lift were measured. Results: The degree of transfer activity changed in 21 patients (17.9%). During follow-up, all patients with SCI at and above C6 showed dependent transfer activities. Eight from 10 patients with SCI at C7, and all patients with SCI at and below C8 performed independent bed-wheelchair transfer activities. Thirty caregivers complained of chronic musculoskeletal pain. The degree of pain at the time of patient transfer was significantly lower in those who used electric-powered lifts compared to manual transfer methods. Caregivers using electric-powered lifts showed significantly better ease-of-use scale than those using manual transfer methods. However, there was no significant difference in the safety scale. Conclusion: The use of electric-powered lifts is essential for patients who cannot perform independent transfers, especially those with SCI at and above C7. (J Korean Acad Rehab Med 2010; 34: 41-48)

Objective
To investigate the current status of respiratory care in community-dwelling amyotrophic lateral sclerosis (ALS) patients using non-invasive ventilatory support. Method: Trained investigators visited patients' homes in order to conduct the survey. Questions regarding the time since diagnosis and ventilatory support, department and type of ventilator were asked. The parameters of mechanical ventilation were noted. The presence of respiratory symptoms, frequency of oxygen saturation monitoring, maneuvers for sputum clearance and frequency of air stacking exercise were also investigated. Results: Data from 169 individuals were analyzed. The mean age was 59.1±12.5 years, time since diagnosis was 48.0±42.8 months and duration of ventilatory support was 25.7±20.8 months. The types of ventilator used were significantly different according to the medical departments where they had been prescribed. More than 50% of the subjects had sleep awakening, shortness of breath or daytime drowsiness despite ventilatory support. Air stacking exercises were performed in 8.8%. Sputum clearing maneuvers such as manually assisted cough, mechanical in/ex-sufflation or postural drainage were used by 13.6% of the individuals. Only 16.0% of the patients checked their oxygen saturation level more than once a day. Conclusion: Current respiratory care is inappropriate in ALS patients using non-invasive ventilatory support at home. The current system for ventilator prescription and monitoring needs modification to improve the respiratory care status. (J Korean Acad Rehab Med 2010; 34: 49-53)

Objective
To investigate the changes of shoulder proprioception in normal subjects, according to the direction of the evoked fatigue on the shoulder muscle group. Method: 20 healthy volunteers (14 males and 6 females, age 20∼35 years) with entirely normal shoulders participated in this study. Before fatigue exercises, the proprioception tests were performed during active reposition (ARP) and passive reposition (PRP) of dominant shoulder, using isokinetic dynamometer, System 3 Pro (Biodex medical system, New York, USA). Three trials each of active and passive repositioning (2°/sec) were recorded. We also estimated the results of the peak torque shoulder movements. The subjects performed maximal efforts with five repetitions on the direction of flexion, abduction, internal rotation and external rotation. The mean values of maximal concentric voluntary contraction (MVC: peak torque of each muscle group contraction) were recorded. We repeated fatigue exercises until the peak torque dropped to 30% three times consistently, then retested the proprioception of shoulder joints. We compared the proprioceptive changes of the shoulder with pre-fatigue test and post-fatigue test on the direction of shoulder movements. Results: There were significant differences of shoulder proprioception between pre-fatigue test and post-fatigue test of ARP in shoulder abduction and external rotation (p＜ 0.05). Conclusion: In our study, the proprioception of shoulder joint decreased more prominently on external rotation and abduction movements under severely provoked muscle fatigue around the shoulder joint. (J Korean Acad Rehab Med 2010; 34: 54-58)

Objective
To investigate differences of the postural control in unstable sitting position between elderly and young adults. Method: Twenty five healthy elderly and twenty five healthy young adults were included. The evaluation system for postural control consisted of unstable plate, frame, safety harness, monitor and computer. Subjects sat on an unstable plate with arms crossed. Using two tilt sensor and postural control software in unstable platform measured the center of pressure (COP) of subject. COP sway (COP was maintained on the center circle and the distance from the central location for 30 sec) time and mean absolute deviation (MAD), COP maintaining (COP was maintained on the desired target in anterior, posterior, left or right directions during 30 sec) time and MAD, COP moving time (the time required to move the COP to desired target location away from center), COP sine curve maintaining (COP was maintained on the circle on moving sine curve during 30 sec) time and MAD were recorded in both groups. Each subject performed three trials and the mean value of the trials was used for analysis. Results: In static evaluation, there was no significant difference in COP sway between two groups. In dynamic evaluations, elderly showed significantly decreased maintaining time in all four directions, decreased sine curve trace and increased moving time in all eight directions (p＜ 0.001). Conclusion: Elderly revealed significantly impaired dynamic sitting postural control, regardless of directions. It might be related to decreased movement and proprioception of trunk. (J Korean Acad Rehab Med 2010; 34: 59-65)

Objective
To evaluate the effect of custom molded foot orthosis without heel lift in scoliosis patients who had different pelvic height caused by inequality of RCSPA (resting calcaneal stance position angle). Method: We retrospectively reviewed the medical data of all patients who had been prescribed custom molded foot orthosis without heel lift in our institution from 2005 to 2009 and chose 38 scoliosis patients with Cobb's angle (≥10^o) and different pelvic height (≥5 mm) caused by inequality of RCSPA (≥2^o). Radiologic findings of whole spine AP and RCSPA were measured pre and post treatment and compared. Results: Twenty two females and sixteen males were included in this study. Their mean age was 7.76±3.72 years. Their mean period of wearing orthosis was 14.11±3.25 months. Initial average Cobb's angle of 13.18±3.16^o were reduced to 7.42±3.45^o (p＜0.001). Initial difference of height between right and left iliac crest of 0.87±0.26 cm reduced to 0.55±0.28 cm (p＜0.01) and angle of pelvic inequality of 3.98±1.55^o reduced to 2.54±1.27^o (p＜0.05). Initial difference of RCSPA between right and left of 3.69±1.54^o decreased to 1.69±1.54^o (p＜0.01). Each parameter has significantly reduced 12 months after the wearing of the custom molded foot orthosis in scoliosis patients whose age was 9 or below, whose Cobb's angle at 15^o or lower. Conclusion: The custom molded foot orthosis without heel lift was effective for scoliosis patients, who had different pelvic height caused by inequality of RCSPA. (J Korean Acad Rehab Med 2010; 34: 66-73)

Objective
To monitor the changes of autonomic nervous function before and after foot bathing through autonomic function tests using electrophysiological instrument. Method: Twenty five healthy adults took a foot bathing through popular 'foot bath' for 30 minutes at 43^oC. Autonomic tests were performed three times before foot bathing, immediately and 15 minutes after foot bathing. Sympathetic skin response (SSR) and blood pressure after sustained grip for sympathetic tone, heart rate variation during deep breathing and Valsalva maneuver for parasympathetic tone (Expiratory/Inspiratory (E/I) ratio, Valsalva ratio) were measured. Results: SSR amplitudes in one hand decreased significantly during foot bathing (p＜0.05) and did not return to their initial levels within 15 minutes after foot bathing. But, blood pressure after sustained grip, E/I ratio and Valsalva ratio did not show statistical difference (p＞0.05). Conclusion: Heat therapy through foot bathing in normal adults reduced sudomotor response to electrical stimuli, which can be considered as reduction of specific sympathetic nervous function. We propose that foot bathing could be promising one of partial heat therapies for pain without cardiovascular complications unlike conventional whole body bathing. (J Korean Acad Rehab Med 2010; 34: 74-78)

Objective
To investigate whether injured corticospinal tract (CST) could recover after rehabilitative therapy in hemiplegic patients with cerebral palsy using diffusion tensor tractography (DTT) which is known to be useful in detecting microscopic white matter lesion in vivo. Method: Sixteen hemiplegic patients (mean age, 13.6 months) were enrolled. Diffuse tensor image (DTI) and gross motor functional measurement (GMFM) evaluation were performed before rehabilitative therapy and at follow-up. We measured the fractional anisotropy (FA), and apparent diffusion coefficient (ADC) of CST in the affected and unaffected hemisphere. To evaluate asymmetry of affected and unaffected CST, asymmetry index of fractional anisotropy (AA) and asymmetry index of apparent diffusion coefficient (AD) were measured. Results: The FA value of the affected CST was lower than that of the unaffected CST and the ADC value was higher than that of the unaffected CST in initial and follow up DTT (p＜0.001). Compared with the result of initial DTT, the results of follow up DTT demonstrated that the FA value of both CST was increased (p=0.000). A significant increase in AA was showed in all patients (p=0.000) and the increase of AA had significant correlation with the increase of FA of affected CST, but not with the unaffected CST (r=0.537, p=0.032). Conclusion: DTT would be a powerful modality not only for diagnosis and prognosis of cerebral palsy, but also assessment of microstructural change of CST after rehabilitative therapy. (J Korean Acad Rehab Med 2010; 34: 79-84)

Objective
To assess the clinical features of children with developmental coordination disorder (DCD) and the effects of occupational therapy. Method: Seventeen children were diagnosed with DCD using by Bruininks-Osteretsky test of motor proficiency (BOTMP). To investigate the clinical features, neurological examinations such as soft neurological signs, speech evaluation, cognitive assessment, and psychiatric evaluation were performed on the 17 participants. Among the participants, 8 children had occupational therapy. BOTMP and cognitive function were evaluated both prior to and 6 months after the intervention. Results: Children with DCD showed various soft neurological signs and co-morbidities such as attention-deficit hyperactivity disorder (ADHD), developmental language disorder, and emotional problems. The cognitive assessment revealed disproportionately low performance IQ for all subjects. After occupational therapy, scores for BOTMP and performance IQ increased significantly. Conclusion: The clinical features of DCD are heterogeneous and occupational therapy focused on motor proficiency was effective. This study supports raising interest in and attention on children with motor coordination difficulties. (J Korean Acad Rehab Med 2010; 34: 85-90)

Treatment of choice for cervical dystonia is botulinum toxin (BTX) injection and surgical interventions can be tried in refractory cases. Success of BTX injection depends on precise muscle selection and adequate dosage of BTX. ¹⁸F- fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) can evaluate the metabolism of the superficial and deep cervical muscles with high resolution and may be useful for identifying dystonic muscles in CD. We report a satisfactory result of BTX injection using ¹⁸F-FDG PET/CT for identification of dystonic muscles in a patient with cervical dystonia who previously failed to respond to botulinum toxin injection and denervation operation. (J Korean Acad Rehab Med 2010; 34: 91-95)

Hypertrophic olivary degeneration is a form of transynaptic degeneration, which is caused by a lesion in the dentate-rubro-olivary pathway. Commonly described lesions were brainstem stroke, neoplasm, demyelination, and trauma. It's clinical presentations are Holmes tremor, and palatal tremor. This case was a 49-year-old man who was diagnosed as bilateral brainstem hemorrhage. About 2 months later, he had developed bilateral Holmes tremor of upper extremities and oculopalatal termor. Brain MRI was performed at 13 months after onset. MRI showed hyperintense and hypertrophied lesion on T2-weighted image in both inferior olivary nuclei. (J Korean Acad Rehab Med 2010; 34: 96-98)

Spinal cord infarction is uncommon and accounts for only 1% of all strokes in comparison with cerebral infarction. Furthermore, posterior spinal cord infarction is particularly rare because of an anastomotic network of direct penetrating vessels and plexus of pial vessels fed by the paired posterior spinal arteries. We report a case of unilateral posterior spinal artery infarction on lower medulla and upper cervical spinal cord in a patient of 60-year-old woman. She complained of continuous headache for several weeks and suddenly presented right facial paresthesia, slow progression of motor weakness and proprioceptive sensory loss on right extremity, and voiding difficulty. Magnetic resonance and computed tomography imaging studies confirmed acute infarction at the right posterolateral aspect of the lower medulla and upper cervical cord (C1-2 level) with right vertebral artery hypoplasia. Transcranial doppler sonography also showed right vertebral artery hypoplasia rather than stenosis with atherosclerosis. (J Korean Acad Rehab Med 2010; 34: 99-102)

Congenital hemiplegia is a subtype of the cerebral palsies characterized by a predominantly spastic movement affecting on side of the body only. It is caused by brain lesions acquired during the prenatal, perinatal, or neonatal periods. It is generally assumed that the damage to the corticospinal tract accounts for most motor deficits in cerebral palsy patients. Ipsilateral motor evoked potentials are likely to be indicative of a profound functional reorganization of corticospinal projections originating from the undamaged hemisphere. The existence of the ipsilateral motor pathway from the unaffected hemisphere has been reported in hemiplegic cerebral palsy using the transcranial magnetic stimulation technique. Here, we report the case of a hemiparetic patient with severe unilateral brain atrophy including brain stem. Transcranial magnetic stimulation to the hypertrophic hemisphere elicited bilateral motor evoked potentials of the first dorsal interossei and ipsilateral responses were shorter onset latencies, implying direct ipsilateral corticospinal projections from the unaffected hemisphere. (J Korean Acad Rehab Med 2010; 34: 103-105)

For patients with bursitis, the treatment modality of choice was conservative treatment, and those who did not experience symptom relief usually received surgery. However, we have been able to treat a patient with chronic proliferative subdeltoid bursitis through alcohol instillation. The patient complained of aggravating right shoulder area pain particularly on abduction or flexion of his arm. Ultrasonographic examination revealed that there was notable synovial thickening, fluid collection and proliferative pannus in the subdeltoid bursa. Steroid was injected for treatment but after 9 days, synovial proliferation and synovial fluid collection remained unchanged. After additional 7 days, 70% isopropyl alcohol 5 ml was injected into the subdeltoid bursa via ultrasonograph-guided injection, followed by normal saline 10 ml injection to dilute the previously injected alcohol in order to re-aspirate. On the following check-up 3 weeks after, decrease in synovial proliferation along with normal ultrasonographic results other than slightly thickened bursa wall was noted. (J Korean Acad Rehab Med 2010; 34: 106-109)

Organophosphate intoxication causing the extrapyramidal symptom is not frequent. A case of Parkinson's syndrome caused by organophosphate intoxication was observed, of which is reported with the quantitative measurement of tremor using Tri-axial accelerometry. A fifty nine year-old male was admitted to Wonju Christian Hospital after the intake of organophosphate for the purpose of suicide and three days after the accident, involuntary movements were detected. The encephalography and MRI showed no abnormality. With Tri-axial accelerometry, we detected less than 4 Hz resting tremor. The tremor did not response to L-dopa, and in the follow up examination performed 149 days after the accident, an increase in amplitude was detected. Gait disturbance and dysarticulation became more severe. In a case of the organophosphate intoxication patient, very rare Parkinson's syndrome findings were detected, and the tremor during the resting period was measured quantitatively by electromyography and Tri-axial accelerometry. (J Korean Acad Rehab Med 2010; 34: 110-113)