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Effectiveness of Neuromuscular Electrical Stimulation on Post-Stroke Dysphagia: A Systematic Review of Randomized Controlled Trials
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To evaluate the effect of caregiver driven robot-assisted in-ward training in subacute stroke patients.
A retrospective evaluation was performed for patients treated with caregiver driven robot-assisted in-ward training to retain gait function from June 2014 and December 2016. All patients received more than 2 weeks of caregiver driven robot-assisted in-ward training after undergoing conventional programs. The robot was used as a sitting device, a standing frame, or a high-walker depending on functional status of the patient. Patients were evaluated before and after robot training. Patient records were assessed by Korean version of Modified Barthel Index (K-MBI), Functional Independence Measure (FIM), and Functional Ambulation Category (FAC).
Initially, patients used the robot as a sitting device (n=6), a standing frame (n=7), or a partial body-weight support high-walker (n=2). As patient functions were improved, usage level of the robot was changed to the next level. At the end of the treatment, the robot was used as a sitting device (n=1), a standing frame (n=6), or high-walker (n=8). Scores of K-MBI (Δ17.47±10.72) and FIM (Δ19.80±12.34) were improved in all patients.
Patients' usage level of the robot and functional scores were improved. Therefore, performing additional caregiver driven robot-assisted in-ward training is feasible and beneficial for subacute stroke patients.
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To demonstrate the usefulness of early videofluoroscopic swallowing study (VFSS) and to investigate change patterns in dietary methods in stroke patients with dysphagia.
The VFSS was performed within 7 days of stroke onset in neurologically stable patients. The patients were divided into three groups according to type of brain lesion: cortical lesion (CL), subcortical lesion (SCL), and brainstem/cerebellar lesion (BCL). Based on the VFSS results, this study investigated change patterns in feeding method and discrepancies in the aspiration risk predicted by the Water Swallowing Test (WST) and the VFSS. Complications, such as aspiration pneumonia, were also evaluated.
A total of 163 patients met the inclusion criteria and the VFSS was performed within 7 days of stroke. Patients considered at risk for aspiration (Penetration-Aspiration Scale [PAS] scores of 6 to 8) were found in all three groups using the VFSS (47.5% of the CL group, 59.3% of the SCL group, and 47.9% of the BCL group). After early VFSS, 79.7% of the patients were assessed to require restricted feeding methods. A 19.0% discrepancy was found between the WST and VFSS results. At 3-week follow-up after the VFSS, aspiration pneumonia was observed in 12 patients (7.4%) with restricted feeding methods.
Early VFSS during the acute period can facilitate determination of the most appropriate feeding method, and support effective dysphagia management for stroke patients.
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To determine the effects of combining robot-assisted game training with conventional upper extremity rehabilitation training (RCT) on motor and daily functions in comparison with conventional upper extremity rehabilitation training (OCT) in stroke patients.
Subjects were eligible if they were able to perform the robot-assisted game training and were divided randomly into a RCT and an OCT group. The RCT group performed one daily session of 30 minutes of robot-assisted game training with a rehabilitation robot, plus one daily session of 30 minutes of conventional rehabilitation training, 5 days a week for 2 weeks. The OCT group performed two daily sessions of 30 minutes of conventional rehabilitation training. The effects of training were measured by a Manual Function Test (MFT), Manual Muscle Test (MMT), Korean version of the Modified Barthel Index (K-MBI) and a questionnaire about satisfaction with training. These measurements were taken before and after the 2-week training.
Both groups contained 25 subjects. After training, both groups showed significant improvements in motor and daily functions measured by MFT, MMT, and K-MBI compared to the baseline. Both groups demonstrated similar training effects, except motor power of wrist flexion. Patients in the RCT group were more satisfied than those in the OCT group.
There were no significant differences in changes in most of the motor and daily functions between the two types of training. However, patients in the RCT group were more satisfied than those in the OCT group. Therefore, RCT could be a useful upper extremity rehabilitation training method.
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To determine the efficacy of a stretching and strengthening exercise program using an upper extremity robot, as compared with a conventional occupational therapy program for upper extremity spasticity in stroke patients.
Subjects were randomly divided into a robot-assisted therapy (RT) group and a conventional rehabilitation therapy (CT) group. RT group patients received RT and CT once daily for 30 minutes each, 5 days a week, for 2 weeks. RT was performed using an upper-extremity robot (Neuro-X; Apsun Inc., Seoul, Korea), and CT was administered by occupational therapists. CT group patients received CT alone twice daily for 30 minutes, 5 days a week, for 2 weeks. Modified Ashworth Scale (MAS) was used to measure the spasticity of upper extremity. Manual muscle tests (MMT), Manual Function Tests (MFT), Brunnstrom stage, and the Korean version of Modified Barthel Index (K-MBI) were used to measure the strength and function of upper extremity. All measurements were obtained before and after 2-week treatment.
The RT and CT groups included 22 subjects each. After treatment, both groups showed significantly lower MAS scores and significant improvement in the MMT, MFT, Brunnstrom stage, and K-MBI scores. Treatment effects showed no significant differences between the two groups.
RT showed similar treatment benefits on spasticity, as compared to CT. The study results suggested that RT could be a useful method for continuous, repeatable, and relatively accurate range of motion exercise in stroke patients with spasticity.
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To investigate the effectiveness of an upper limb rehabilitation robot therapy on hemispatial neglect in stroke patients.
Patients were randomly divided into an upper limb rehabilitation robot treatment group (robot group) and a control group. The patients in the robot group received left upper limb training using an upper limb rehabilitation robot. The patients sat on the right side of the robot, so that the monitor of the robot was located on the patients' left side. In this position, patients could focus continuously on the left side. The control group received conventional neglect treatment, such as visual scanning training and range of motion exercises, administered by occupational therapists. Both groups received their respective therapies for 30 minutes a day, 5 days a week for 3 weeks. Several tests were used to evaluate treatment effects before and after the 3-week treatment.
In total, 38 patients (20 in the robot group and 18 in the control group) completed the study. After completion of the treatment sessions, both groups showed significant improvements in the Motor-Free Visual Perception Test 3rd edition (MVPT-3), the line bisection test, the star cancellation test, the Albert's test, the Catherine Bergego scale, the Mini-Mental State Examination and the Korean version of Modified Barthel Index. The changes in all measurements showed no significant differences between the two groups.
This present study showed that the upper limb robot treatment had benefits for hemispatial neglect in stroke patients that were similar to conventional neglect treatment. The upper limb robot treatment could be a therapeutic option in the treatment of hemispatial neglect after stroke.
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To describe the correlation between the functional dysphagia scale and aspiration pneumonia and which characteristics influence the occurrence of aspiration pneumonia in patients with idiopathic Parkinson disease.
Fifty-three patients with idiopathic Parkinson disease were prospectively evaluated in this study. Disease severity and functional status were measured by modified Hoehn and Yahr (H&Y) staging, Schwab and England activities of daily living (S-E ADL) scale and Korean version of Mini-Mental State Examination (K-MMSE). Swallowing function was evaluated by the functional dysphagia scale (FDS) and the penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study. The patients were followed up for 3 months and divided into two groups according to the occurrence of aspiration pneumonia. The correlation between the variables and aspiration pneumonia was analyzed.
Eight patients of the 53 patients were allocated to the aspiration pneumonia group and 45 patients to the non-aspiration pneumonia group. The patients in the aspiration pneumonia group had significantly higher H&Y staging, and scored lower on S-E ADL scale and K-MMSE. The patients in the aspiration pneumonia group had significantly higher scores on FDS and PAS. A multiple logistic regression analysis showed that the S-E ADL scale and the FDS were associated with the occurrence of aspiration pneumonia in the patients with Parkinson disease.
Given that the FDS can quantitatively assess the functional problems associated with dysphagia, it can be clinically effective in predicting the occurrence of aspiration pneumonia, and the FDS and the S-E ADL scale could be predictive variables for aspiration pneumonia in patients with Parkinson disease.
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To investigate how much formal caregivers know about caring for stroke patients, and whether they adequately provide it.
Formal caregivers, who worked for stroke patients at 8 hospitals (including 4 university hospitals, 2 rehabilitation hospitals, and 2 convalescent hospitals) participated in this study. The survey was based on a self-report questionnaire, with 6 categories containing a total of 48 questions about the specific care of stroke patients: the demographic characteristics of the caregivers, bed positioning, the provision of meals, position changes and transfers, the range of motion exercises, and caregiver training.
A total of 217 caregivers were surveyed, and they were distributed as follows: 41% came from the university hospitals, 35% came from the rehabilitation hospitals, and 24% came from the convalescent hospitals. The percentages of correct answers were distributed as follows: 64.3% for bed positioning, 74.3% for providing meals, and 62.4% for position change and transfer. The total and subscale scores of the caregivers working at convalescent hospitals were significantly lower than those of the caregivers working at the other types of hospitals (p<0.05). Only 7.8% of the total participants received training on a regular basis. The caregivers obtained most of the information from caregiver associations (58.1%), and the majority of the caregivers (65.4%) were willing to receive training.
About one third (33.8%) of caregivers did not have adequate knowledge of how to properly care for stroke patients; in fact, a significant number of caregivers demonstrated inappropriate and insufficient knowledge in several areas. It is assumed that the provision of regular training, by rehabilitation experts, will improve the professionalism and knowledge of the caregivers, and positively affect patient outcomes.
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To investigate the effect of repetitive transcranial magnetic stimulation (rTMS) according to the stimulation site in subacute stroke patients with dysphagia.
This study was designed as a matched comparative study. Twenty-four patients who had dysphagia after ischemic stroke were recruited, and they were divided into two groups after matching for age and stroke lesion. The patients in group A received rTMS over the brain cortex where motor evoked potential (MEP) was obtained from the suprahyoid muscle. Group B received rTMS over the brain cortex where MEP was obtained from the abductor pollicis brevis muscle. rTMS was performed at 110% of MEP threshold, 10 Hz frequency for 10 seconds, and then repeated every minute for 10 minutes. Dysphagia status was measured by the Functional Dysphagia Scale (FDS), the Penetration-Aspiration Scale (PAS), and the Dysphagia Outcome and Severity Scale (DOSS) using the results of a videofluoroscopic swallowing study. These evaluations were measured before, immediately, and 4 weeks after rTMS.
Group A showed significant improvement compared to group B in the DOSS score immediately and 4 weeks after rTMS. There were no significant differences in the changes of FDS and PAS scores between groups A and B immediately and 4 weeks after rTMS.
rTMS over a hot spot for the suprahyoid muscle caused more improvement in swallowing function when compared to that over the interconnected site.
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To determine factors associated with motor recovery of the upper extremity after repetitive transcranial magnetic stimulation (rTMS) treatment in stroke patients.
Twenty-nine patients with subacute stroke participated in this study. rTMS was applied to the hand motor cortex for 10 minutes at a 110% resting motor threshold and 10 Hz frequency for two weeks. We evaluated the biographical, neurological, clinical, and functional variables, in addition to the motor-evoked potential (MEP) response. The Manual Function Test (MFT) was performed before, immediately after, and two weeks after, the treatment. Patients were divided into a responder and non-responder group according to their respective improvements on the MFT. Data were compared between the two groups.
Patients with exclusively subcortical stroke, absence of aphasia, the presence of a MEP response, high scores on the Mini-Mental Status Examination, Motricity Index arm score, Functional Independence Measure, and Functional Ambulatory Classification; and a shorter period from stroke onset to rTMS were found to be significantly associated with a response to rTMS.
The results of this study suggest that rTMS may have a greater effect on upper extremity motor recovery in stroke patients who have a MEP response, suffer an exclusively subcortical stroke, mild paresis, and have good functional status. Applying rTMS early would have additional positive effects in the patients with the identified characteristics.
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To compare the outcome of an early application of neuromuscular electrical stimulation (NMES) combined with traditional dysphagia therapy (TDT) versus traditional dysphagia therapy only in acute/subacute ischemic stroke patients with moderate to severe dysphagia by videofluoroscopic swallowing study (VFSS).
Fifty-seven dysphagic stroke patients were enrolled in a VFSS within 10 days after stroke onset. Patients were randomly assigned into two treatment groups. Thirty-one patients received NMES combined with TDT (NMES/TDT group) and 26 patients received TDT only (TDT group). Electrical stimulation with a maximal tolerable intensity was applied on both suprahyoid muscles for 30 minutes, 5 days per week during 3 weeks. The swallowing function was evaluated at baseline and 3, 6, and 12 weeks after baseline. Outcomes of the VFSS were assessed using the Functional Oral Intake Scale (FOIS).
The mean ages were 63.5±11.4 years in the NMES/TDT group and 66.7±9.5 years in the TDT group. Both groups showed a significant improvement on the FOIS after treatment. The FOIS score was significantly more improved at 3 and 6 weeks after baseline in the NMES/TDT group than in the TDT group (p<0.05).
An early application of NMES combined with TDT showed a positive effect in acute/subacute ischemic stroke patients with dysphagia. These results indicated that the early application of NMES could be used as a supplementary treatment of TDT to help rehabilitate acute/subacute dysphagic stroke patients by improving their swallowing coordination.
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Effectiveness of Neuromuscular Electrical Stimulation on Post-Stroke Dysphagia: A Systematic Review of Randomized Controlled Trials
To demonstrate associating factors regarding nasogastric tube (NGT) removal in patients with dysphagia after stroke.
This study is a retrospective medical chart review. Patients were divided into non-brain stem (NBS) and brain stem (BS) groups. A videofluoroscopic swallowing study was conducted until swallowing functions were recovered. Initial disease status was measured using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). Risk factors related to stroke were evaluated. The penetration-aspiration scale (PAS) was used as the swallowing test. Functional status was measured by Mini-Mental Status Examination (MMSE) and Modified Barthel Index (MBI). Within each group, initial evaluations and their subsequent changes were compared according to the NGT removal status. Correlation between the NGT removal time and other initial factors were evaluated.
Ninety-nine patients were allocated to the NBS group and 39 to the BS group. In NBS, age, PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, smoking and PAS were significantly different. In NBS, changes in PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, only PAS change was significantly different. In NBS, initial NIHSS, mRS, MMSE, and MBI were correlated with removal time.
In stroke patients with NTG, younger age, better initial disease and functional status seems to remove NGT in NBS stroke. Therefore, when deciding to remove NGT, those three factors should be considered discreetly.
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To investigate the somatosensory findings of pusher syndrome in stroke patients.
Twelve pusher patients and twelve non-pusher patients were enrolled in this study. Inclusion criteria were unilateral stroke, sufficient cognitive abilities to understand and follow instructions, and no visual problem. Patients were evaluated for pusher syndrome using a standardized scale for contraversive pushing. Somatosensory finding was assessed by the Cumulative Somatosensory Impairment Index (CSII) and somatosensory evoked potentials (SEPs) at 1 and 14 weeks after the stroke onset. Data of SEPs with median and tibial nerve stimulation were classified into the normal, abnormal, and no response group.
In the baseline characteristics (sex, lesion character, and side) of both groups, significant differences were not found. The score of CSII decreased in both groups at 14 weeks (p<0.05), but there were no significant differences in the CSII scores between the two groups at 1 and 14 weeks. There were no significant differences in SEPs between the two groups at 1 and 14 weeks after the stroke onset.
It appears that somatosensory input plays a relatively minor role in pusher syndrome. Further study will be required to reveal the mechanism of pusher syndrome.
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To evaluate the effect of hyaluronidase in patients with failed back surgery syndrome (FBSS) treated with interlaminar lumbar epidural injection (ILEI).
Sixty patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T received ILEI with 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. Group H received ILEI with 1500 IU hyaluronidase and 5 ml bupivacaine 0.25%. Group TH received interlaminar lumbar epidural injection (ILEI) with 1500 IU hyaluronidase, 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. The effect was evaluated using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at pre-injection, 2 weeks, 6 weeks and 12 weeks after ILEI.
After 2 weeks and after 6 weeks, patients in both Group T and Group TH had significant effectiveness more than Group H in decrease of VAS and ODI. After 12 weeks, only patients in Group TH had significant effectiveness in decrease of VAS and ODI (p<0.05). In every period, Group TH had the most effectivess in decrease of VAS and ODI after ILEI.
ILEI for FBSS with triamcinolone and hyaluronidase is considered to have more long term effectiveness to reduce pain and improve function after ILEI than injection with triamcinolone alone or hyaluronidase alone.
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To evaluate the effect of prolonged inpatient rehabilitation therapy in subacute stroke patients.
We enrolled 52 subacute stroke patients who had received 3 months of inpatient rehabilitation therapy. Thirty stroke patients received additional inpatient rehabilitation therapy for 3 months and 22 control patients received only home-based care. The evaluation was measured at 3 and at 6 months after stroke occurrence. Functional improvement was measured using the modified motor assessment scale (MMAS), the timed up and go test (TUG), the 10-meter walking time (10 mWT), the Berg balance scale (BBS) and the Korean-modified Barthel index (K-MBI). The health-related quality of life was evaluated using the medical outcome study, 36-item short form survey (SF-36).
In the experimental group, significant improvements were observed for all parameters at 6 months (p<0.05). However, significant improvements were observed only in MMAS, BBS, and K-MBI at 6 months in the Control group (p<0.05). In comparing the 2 groups, significant difference were observed in all parameters (p<0.05) except 10 meter walking time (p=0.73). The improvement in SF-36 was meaningfully higher in experimental group compared to control group.
This study demonstrates that subacute stroke patients can achieve functional improvements and an enhanced quality of life through prolonged inpatient rehabilitation therapy.
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To evaluate the effect of hyaluronidase in lumbar interlaminar epidural injection (LIEI) for low back pain and sciatica.
Sixty-one patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T (n=18, mean duration of illness: 2.12±1.16 months) received lumbar interlaminar epidural injection (LIEI) with 2 ml triamcinolone (40 mg/ml) and 5 ml bupivacaine (0.25%). Group H (n=16, mean duration of illness: 2.05±1.12 months) received LIEI with 1,500 IU hyaluronidase and 5 ml bupivacaine (0.25%). Group TH (n=27, mean duration of illness: 2.16±1.65 months) received LIEI with 1,500 IU hyaluronidase, 2 ml triamcinolone (40 mg/ml), and 5 ml bupivacaine (0.25%). The effects were evaluated using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at preinjection and 2 weeks, 4 weeks, and 8 weeks after LIEI.
Pain improved in all groups after 2 weeks (p<0.05). After 8 weeks, there was no significant difference in VAS improvement among the 3 groups. However, pain improved in 70.4% of Group TH compared with preinjection, in contrast to 44.4% of Group T and 31.3% of Group H. The ODI improved significantly only in Group TH after 8 weeks (p<0.05).
LIEI with triamcinolone and hyaluronidase is more effective for reducing pain after 8 weeks than injection with triamcinolone or hyaluronidase alone.
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