Publications by authors named "Hee-Kyu Kwon"

27 Publications

  • Page 1 of 1

Clinical Factors Associated with Balance Function in the Early Subacute Phase after Stroke.

Am J Phys Med Rehabil 2021 Jul 27. Epub 2021 Jul 27.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Republic of Korea Brain Convergence Research Center, Korea University, Seoul, Republic of Korea Department of Biomedical Sciences, Korea University, Seoul, Republic of Korea.

Objective: To investigate the key factors of balance function in the early subacute phase after stroke.

Design: Ninety-four stroke patients were included. Multiple variables were evaluated, including demographic factors, clinical variables (stroke type; lesion site; Korean Mini-Mental State Examination [MMSE]; motor strength of the hip, knee, and ankle joints; Fugl-Meyer Assessment of lower extremity [FMA-LE]); neurophysiologic variables (amplitude ratio of somatosensory evoked potential [SEP] of the tibial nerves), and laterality index of fractional anisotropy (FA-LI) of the corticospinal tract using diffusion tensor imaging. Balance function was measured using the Berg balance scale (BBS).

Results: The BBS score was significantly negatively correlated with age and FA-LI and positively correlated with MMSE; FMA-LE; motor strength of the affected hip, knee, and ankle joint; and SEP amplitude ratio (p < 0.05). The abnormal SEP group and poor integrity of the corticospinal tract group showed significantly decreased BBS scores. In multivariable logistic regression analysis, age, FMA-LE score, and ankle plantar flexion strength were significantly associated with balance function (odds ratios: 0.919, 1.181, and 15.244, respectively, p < 0.05).

Conclusion: Higher age, severe initial motor impairment, and strength of the affected lower extremity muscles, especially the ankle plantar flexor, are strongly associated with poor balance function early after stroke.
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http://dx.doi.org/10.1097/PHM.0000000000001856DOI Listing
July 2021

Palmar Digital Neuropathy With Anatomical Variation of Median Nerve: Usefulness of Orthodromic Technique: A Case Report.

Ann Rehabil Med 2019 Jun 28;43(3):341-346. Epub 2019 Jun 28.

Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, Korea.

Anatomic variation of palmar digital nerve pathways were reported in several cases. Selective exploration of palmar digital nerves with a nerve conduction study has been challenging, because of technical issues. We report a patient who received bilateral carpal tunnel release operation, complaining of a tingling sensation, and hypoesthesia on the middle and ring fingers. An electrodiagnostic study revealed a sensory neuropathy of palmar digital nerve of the left median nerve, supplying the ulnar side of the middle finger, and radial side of the ring finger. She underwent re-operation of open left carpal tunnel release, and a branching site of common digital nerves of the median nerve was identified not at the palm, but at a far proximal site around the distal wrist crease. Usefulness of an orthodromic sensory conduction study was clarified to eliminate volume conducted response or co-activation of nearby nerves in the patient with selective involvement of palmar digital nerve.
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http://dx.doi.org/10.5535/arm.2019.43.3.341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6637065PMC
June 2019

Early Detection of Diabetic Polyneuropathy Using Paired Stimulation Studies of the Sensory Nerves.

Am J Phys Med Rehabil 2019 11;98(11):982-988

From the Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, South Korea.

Objective: This study seeks to use the relative refractory period, a sensitive parameter for detecting early change in peripheral polyneuropathies, as a tool for early detection of diabetic polyneuropathy.

Design: The relative refractory period of the median and sural sensory nerves was measured in 57 diabetic patients (male 31, female 26) and 23 healthy controls (male 16, female 7). The shortest interstimulus interval, where the latency of the response to the second stimulus recovers to normal, was defined as the relative refractory period.

Results: The relative refractory period of the median and sural nerves were significantly longer in diabetic patients (3.6 msec, P < 0.001, and 3.8 msec, P < 0.001, respectively) than in the control group (3.0 msec in both nerves). Relative refractory period values of both nerves were also significantly prolonged compared with the control group, even in diabetic patients without diabetic polyneuropathy based on conventional conduction studies (3.3 msec, P = 0.002, for median nerve; 3.5 msec, P < 0.001, for sural nerve) or without any clinical symptoms and signs (3.3 msec, P = 0.007, for median nerve; 3.5 msec, P = 0.001, for sural nerve).

Conclusions: The relative refractory period was prolonged in diabetic patients even before other electrophysiologic abnormalities or clinical findings appeared. These results suggest that the relative refractory period can be a possible early indicator of diabetic polyneuropathy.
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http://dx.doi.org/10.1097/PHM.0000000000001229DOI Listing
November 2019

Complex Regional Pain Syndrome of Non-hemiplegic Upper Limb in a Stroke Patient: A Case Report.

Ann Rehabil Med 2018 Feb 28;42(1):175-179. Epub 2018 Feb 28.

Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, Korea.

Complex regional pain syndrome (CRPS) type I in stroke patients is usually known to affect the hemiplegic upper limb. We report a case of CRPS presented in an ipsilesional arm of a 72-year-old female patient after an ischemic stroke at the left middle cerebral artery territory. Clinical signs such as painful range of motion and hyperalgesia of her left upper extremity, swollen left hand, and dystonic posture were suggestive of CRPS. A three-phase bone scintigraphy showed increased uptake in all phases in the ipsilesional arm. Diffusion tensor tractography showed significantly decreased fiber numbers of the corticospinal tract and the spinothalamic tract in both unaffected and affected hemispheres. Pain and range of motion of the left arm of the patient improved after oral steroids with a starting dose of 50 mg/day.
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http://dx.doi.org/10.5535/arm.2018.42.1.175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852221PMC
February 2018

Sonography of Carpal Tunnel Syndrome According to Pathophysiologic Type: Conduction Block Versus Axonal Degeneration.

J Ultrasound Med 2017 May 4;36(5):993-998. Epub 2017 Mar 4.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea.

Objectives: The purpose of this study was to investigate sonographic findings according to the pathophysiologic type in patients with carpal tunnel syndrome.

Methods: We retrospectively reviewed the records of 80 patients (148 hands) with carpal tunnel syndrome. Patients were classified into 3 groups according to electrophysiologic findings: (1) conduction block and conduction delay; (2) axonal degeneration; and (3) mixed. We used sonographic evaluations to assess the cross-sectional area at the distal wrist crease and the distal forearm and the wrist-to-forearm ratio of the median nerve.

Results: Patients with axonal degeneration had significantly larger cross-sectional areas and wrist-to-forearm ratios than those with a conduction block (P < .05). The increased wrist-to-forearm ratio correlated with a reduced amplitude of the sensory nerve action potential, which reflects the degree of axonal degeneration.

Conclusions: The cross-sectional area and wrist-to-forearm ratio were associated with the pathophysiologic type of carpal tunnel syndrome, with larger nerve swellings seen in patients with axonal degeneration compared with those with demyelinating lesions. In addition to helping in the localization of the nerve lesion, sonography may indicate the type of nerve lesion.
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http://dx.doi.org/10.7863/ultra.16.05019DOI Listing
May 2017

Neural substrates of lower extremity motor, balance, and gait function after supratentorial stroke using voxel-based lesion symptom mapping.

Neuroradiology 2016 Jul 10;58(7):723-31. Epub 2016 Mar 10.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Inchon-Ro 73, Seongbuk-Gu, Seoul, 02841, Republic of Korea.

Introduction: Stroke impairs motor, balance, and gait function and influences activities of daily living. Understanding the relationship between brain lesions and deficits can help clinicians set goals during rehabilitation. We sought to elucidate the neural substrates of lower extremity motor, balance, and ambulation function using voxel-based lesion symptom mapping (VLSM) in supratentorial stroke patients.

Methods: We retrospectively screened patients who met the following criteria: first-ever stroke, supratentorial lesion, and available brain magnetic resonance imaging (MRI) data. MRIs of 133 stroke patients were selected for VLSM analysis. We generated statistical maps of lesions related to lower extremity motor (lower extremity Fugl-Meyer assessment, LEFM), balance (Berg Balance Scale, BBS), and gait (Functional Ambulation Category, FAC) using VLSM.

Results: VLSM revealed that lower LEFM scores were associated with damage to the bilateral basal ganglia, insula, internal capsule, and subgyral white matter adjacent to the corona radiata. The lesions were more widely distributed in the left than in the right hemisphere, representing motor and praxis function necessary for performing tasks. However, no associations between lesion maps and balance and gait function were established.

Conclusion: Motor impairment of the lower extremities was associated with lesions in the basal ganglia, insula, internal capsule, and white matter adjacent to the corona radiata. However, VLSM revealed no specific lesion locations with regard to balance and gait function. This might be because balance and gait are complex skills that require spatial and temporal integration of sensory input and execution of movement patterns. For more accurate prediction, factors other than lesion location need to be investigated.
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http://dx.doi.org/10.1007/s00234-016-1672-3DOI Listing
July 2016

Relationship of Vascular Factors on Electrophysiologic Severity of Diabetic Neuropathy.

Ann Rehabil Med 2016 Feb 26;40(1):56-65. Epub 2016 Feb 26.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea.

Objective: To investigate the impact of vascular factors on the electrophysiologic severity of diabetic neuropathy (DPN).

Methods: Total 530 patients with type 2 diabetes were enrolled retrospectively. We rated severity of DPN from 1 (normal) to 4 (severe) based on electrophysiologic findings. We collected the data concerning vascular factors (including brachial-ankle pulse wave velocity [PWV], ankle brachial index, ultrasound of carotid artery, lipid profile from the blood test, and microalbuminuria [MU] within 24 hours urine), and metabolic factors of diabetes (such as glycated hemoglobin [HbA1c]). We analyzed the differences among the four subgroups using χ(2) test and ANOVA, and ordinal logistic regression analysis was performed to investigate the relationship between significant variables and severity of DPN.

Results: The severity of DPN was significantly associated with duration of diabetes, HbA1c, existence of diabetic retinopathy and nephropathy, PWV, presence of plaque, low density lipoprotein-cholesterol and MU (p<0.05). Among these variables, HbA1c and presence of plaque were more significantly related with severity of DPN in logistic regression analysis (p<0.001), and presence of plaque showed the highest odds ratio (OR=2.52).

Conclusion: Our results suggest that markers for vascular wall properties, such as PWV and presence of plaque, are significantly associated with the severity of DPN. The presence of plaque was more strongly associated with the severity of DPN than other variables.
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http://dx.doi.org/10.5535/arm.2016.40.1.56DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775759PMC
February 2016

Reappraisal of Supraorbital Sensory Nerve Conduction Recordings: Orthodromic and Antidromic Techniques.

Ann Rehabil Med 2016 Feb 26;40(1):43-9. Epub 2016 Feb 26.

Department of Physical Medicine and Rehabilitation, Korea University School of Medicine, Seoul, Korea.

Objective: To establish a supraorbital nerve sensory conduction recording method and assess its usefulness.

Methods: Thirty-one healthy subjects without a history of trauma or neurological disease were recruited. For the orthodromic procedure, the recording electrode was attached immediately superior to the supraorbital notch. The stimulation electrode was placed on points along the hairline which evoked the largest sensory nerve action potentials (SNAPs). The antidromic sensory response was recorded after switching the recording and stimulating electrodes. The measured parameters were onset latency, peak latency, and baseline to peak amplitude of the SNAPs. The electrophysiological parameters of the bilateral supraorbital nerves were compared. We also recruited two patients who had sensory deficits on one side of their foreheads because of laceration injuries.

Results: The parameters of orthodromically recorded SNAPs were as follows: onset latency 1.21±0.22 ms (range, 0.9-1.6 ms), peak latency 1.54±0.23 ms (range, 1.2-2.2 ms), and baseline to peak amplitude 4.16±1.92 µV (range, 1.4-10 µV). Those of antidromically recorded SNAPs were onset latency 1.31±0.27 ms (range, 0.8-1.7 ms), peak latency 1.62±0.29 ms (range, 1.3-2.2 ms), and baseline to peak amplitude 4.00±1.89 µV (range, 1.5-9.0 µV). There was no statistical difference in onset latency, peak latency, or baseline to peak amplitude between the responses obtained using the orthodromic and antidromic methods, and the parameters also revealed no statistical difference between the supraorbital nerves on both sides.

Conclusion: We have successfully recorded supraorbital SNAPs. This conduction technique could be quite useful in evaluating patients with supraorbital nerve lesions.
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http://dx.doi.org/10.5535/arm.2016.40.1.43DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775757PMC
February 2016

Efficacy of Optimal Recording Electrode Placement for Median-Lumbrical and Ulnar-Interossei/Lumbrical Distal Latency in the Diagnosis of Carpal Tunnel Syndrome.

J Clin Neurophysiol 2016 Apr;33(2):162-5

*Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University, Seoul, Korea; and †Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seongnam-si, Korea.

Purpose: This study is to determine the diagnostic utility of optimal recording electrode placement for distal latency comparison of median-second lumbrical and ulnar-interossei/third lumbrical (M2L-UI3L) in carpal tunnel syndrome.

Methods: Sixty-five hands of control and 75 hands of 62 clinically suspected carpal tunnel syndromes were used for the M2L-UI3L and standard conduction studies. To obtain optimal M2L-UI3L, the recording active electrode (E1) was placed at the midpalm over the third metacarpal bone, whereas the reference electrode (E2) was attached to the palmar digital crease area. Then, median and ulnar nerves were stimulated on the wrist each at 8 cm proximal to E1. M2L-UI3L and standard nerve conduction studies were performed. Sensitivity and specificity of M2L-UI3L were measured in the diagnosis of mild carpal tunnel syndrome.

Results: For statistical analysis, the receiver operating characteristics and Student t-test were used. The area under the receiver operating characteristic curve of M2L-UI3L was 0.993. Diagnostic cutoff value of M2L-UI3L greater than 0.6 milliseconds yields sensitivity of 93% and specificity of 97%. The distal median motor latency to the second lumbrical alone showed the area under the curve of 0.998, and the diagnostic cutoff value greater than 3.4 milliseconds yields sensitivity of 96% and specificity of 100%.

Conclusions: This technique for M2L-UI3L shows high sensitivity and specificity compared with the previous reports on the diagnosis of carpal tunnel syndrome. Furthermore, the values of median-second lumbrical motor latency alone have higher sensitivity and specificity, comparable with the median sensory conduction study across the wrist segment.
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http://dx.doi.org/10.1097/WNP.0000000000000242DOI Listing
April 2016

Correlation between Ultrasonography Findings and Electrodiagnostic Severity in Carpal Tunnel Syndrome: 3D Ultrasonography.

J Clin Neurol 2014 Oct 6;10(4):348-53. Epub 2014 Oct 6.

Department of Physical Medicine & Rehabilitation, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Background And Purpose: To determine the correlation between the cross-sectional area (CSA) of the median nerve measured at the wrist using three-dimensional (3D) ultrasonography (US) and the electrophysiological severity of carpal tunnel syndrome (CTS).

Methods: We prospectively examined 102 wrists of 51 patients with clinical CTS, which were classified into 3 groups according to the electrodiagnostic (EDX) findings. Median nerve CSAs were measured using 3D US at the carpal tunnel inlet and at the level of maximal swelling.

Results: Ten wrists were negative for CTS. Of the 92 CTS-positive wrists, 23, 30, and 39 were classified as having mild, moderate, and severe CTS, respectively. The median nerve CSA differed significantly between the severe- and moderate-CTS groups (p=0.0007 at the carpal tunnel inlet and p<0.0001 at the maximal swelling site). There was a correlation between median nerve CSA and EDX parameters among those wrists with severe and mild CTS (p<0.0001 at both sites).

Conclusions: The median nerve CSA as measured by 3D US could provide additional information about the severity of CTS, as indicated by the strong correlation with standard EDX findings.
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http://dx.doi.org/10.3988/jcn.2014.10.4.348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4198717PMC
October 2014

Sonography of the median nerve in carpal tunnel syndrome with diabetic neuropathy.

Am J Phys Med Rehabil 2014 Oct;93(10):897-907

From the Department of Physical Medicine & Rehabilitation, Sahmyook Medical Center, Seoul, Republic of Korea (L-NK); Department of Physical Medicine & Rehabilitation, College of Medicine, Korea University, Seoul, Republic of Korea (H-KK, H-IM, S-BP); and Department of Physical Medicine & Rehabilitation, College of Medicine, Bundang CHA Medical Center, Sungnam City, Gyeonggi Province, Republic of Korea (H-JL).

Objective: The aim of this study was to determine the criteria for ultrasonographic measurement of the cross-sectional area (CSA) of the median nerve and differential diagnosis of patients with carpal tunnel syndrome (CTS) with or without diabetic polyneuropathy (DPN).

Design: One hundred eighty-seven patients were divided into five groups: healthy controls, CTS, diabetes with CTS but without DPN, DPN only, and both DPN and CTS. The CSAs of the median nerve were measured at four levels, and cutoff values to diagnose CTS with DPN were obtained.

Results: All the CSAs were larger in the DPN group compared with those in the control group. The CSAs of the median nerve at the wrist revealed no significant differences among the groups with CTS; however, these groups demonstrated larger CSAs at the wrist and a higher wrist/forearm ratio compared with the DPN only group. The cutoff value for the CSA at the wrist that yielded the highest sensitivity and specificity was 11.6 mm.

Conclusions: The CSA of the median nerve at the wrist and the wrist/forearm ratio could be useful for diagnosing the comorbidity of CTS with DPN.
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http://dx.doi.org/10.1097/PHM.0000000000000084DOI Listing
October 2014

Ultrasonography of palm to elbow segment of median nerve in different degrees of diabetic polyneuropathy.

Clin Neurophysiol 2014 Apr 5;125(4):844-848. Epub 2013 Nov 5.

Bundang Cha Medical Center, South Korea.

Objective: To identify the relationship between the ultrasonographic cross-sectional area (CSA) of the median nerve and electrophysiologic findings in diabetic patients.

Methods: Sixty diabetic patients, 30 patients with carpal tunnel syndrome (CTS) and 30 healthy volunteers participated. The participants were divided into 4 groups: Control Group; Group I, diabetic patients without diabetic polyneuropathy (DPN); Group II, diabetic patients with DPN; and Group III, patients with CTS. Group II was subdivided into II-1 and II-2 according to DPN severity. The median nerve CSA was measured at 4 levels, and the wrist-to-forearm ratio (WFR) was calculated.

Results: The median nerve CSAs were larger in Group II than in Group I and the Control Group. There were significant differences in the CSA between Group I and Group II-2 and between Group II-1 and II-2. There was no significant difference in the WFR among these groups. The CSAs at the wrist levels and WFR were significantly greater in Group III.

Conclusions: The median nerve CSA was greater in patients with DPN and was related to DPN severity. Diffuse increase in median nerve CSA without change in the WFR might be compatible with DPN. Ultrasonography could be applied for the diagnosis of DPN, especially in advanced cases.

Significance: Ultrasonography might have value in the differential diagnosis of DPN and entrapment neuropathy.
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http://dx.doi.org/10.1016/j.clinph.2013.10.041DOI Listing
April 2014

Diagnosis of zygomaticus muscle paralysis using needle electromyography with ultrasonography.

Ann Rehabil Med 2013 Jun 30;37(3):433-7. Epub 2013 Jun 30.

Department of Rehabilitation Medicine, Korea University College of Medicine, Seoul, Korea.

A 22-year-old woman visited our clinic with a history of radiofrequency volumetric reduction for bilateral masseter muscles at a local medical clinic. Six days after the radiofrequency procedure, she noticed a facial asymmetry during smiling. Physical examination revealed immobility of the mouth drawing upward and laterally on the left. Routine nerve conduction studies and needle electromyography (EMG) in facial muscles did not suggest electrodiagnostic abnormalities. We assumed that the cause of facial asymmetry could be due to an injury of zygomaticus muscles, however, since defining the muscles through surface anatomy was difficult and it was not possible to identify the muscles with conventional electromyographic methods. Sono-guided needle EMG for zygomaticus muscle revealed spontaneous activities at rest and small amplitude motor unit potentials with reduced recruitment patterns on volition. Sono-guided needle EMG may be an optimal approach in focal facial nerve branch injury for the specific localization of the injury lesion.
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http://dx.doi.org/10.5535/arm.2013.37.3.433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713303PMC
June 2013

Nerve conduction studies of median motor nerve and median sensory branches according to the severity of carpal tunnel syndrome.

Ann Rehabil Med 2013 Apr 30;37(2):254-62. Epub 2013 Apr 30.

Department of Physical Medicine and Rehabilitation, National Rehabilitation Center, Seoul, Korea.

Objective: To evaluate each digital branch of the median sensory nerve and motor nerves to abductor pollicis brevis (APB) and 2nd lumbrical (2L) according to the severity of carpal tunnel syndrome (CTS).

Methods: A prospective study was performed in 67 hands of 41 patients with CTS consisting of mild, 23; moderate, 27; and severe cases, 17. Compound muscle action potentials (CMAPs) were obtained from APB and 2L, and median sensory nerve action potentials (SNAPs) were recorded from the thumb to the 4th digit. Parameters analyzed were latency of the median CMAP, latency difference of 2L and first palmar interosseous (PI), as well as latency and baseline to peak amplitude of the median SNAPs.

Results: The onset and peak latencies of the median SNAPs revealed significant differences only in the 2nd digit, according to the severity of CTS, and abnormal rates of the latencies were significantly lower in the 2nd digit to a mild degree. The amplitude of SNAP and sensory nerve conduction velocities were more preserved in the 2nd digit in mild CTS and more affected in the 4th digit in severe CTS. CMAPs were not evoked with APB recording in 4 patients with severe CTS, but obtained in all patients with 2L recording. 2L-PI showed statistical significance according to the severity of CTS.

Conclusion: The branch to the 4th digit was mostly involved and the branch to the 2nd digit and 2L were less affected in the progress of CTS. The second digit recorded SNAPs and 2L recorded CMAPs would be valuable in the evaluation of severe CTS.
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http://dx.doi.org/10.5535/arm.2013.37.2.254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3660488PMC
April 2013

Correlation between Location of Brain Lesion and Cognitive Function and Findings of Videofluoroscopic Swallowing Study.

Ann Rehabil Med 2012 Jun 30;36(3):347-55. Epub 2012 Jun 30.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul 136-705, Korea.

Objective: To investigate whether patterns of swallowing difficulties were associated with the location of the brain lesion, cognitive function, and severity of stroke in stroke patients.

Method: Seventy-six patients with first-time acute stroke were included in the present investigation. Swallowing-related parameters, which were assessed videofluoroscopically, included impairment of lip closure, decreased tongue movement, amount of oral remnant, premature loss of food material, delay in oral transit time, laryngeal elevation, delay in pharyngeal triggering time, presence of penetration or aspiration, and the amount of vallecular and pyriform sinus remnants. The locations of brain lesions were classified into the frontal, parietotemporal, subcortical, medulla, pons, and cerebellum. The degree of cognitive impairment and the severity of stroke were assessed by the Mini Mental Status Examination (MMSE) and the National Institute of Health Stroke Scale (NIHSS), respectively.

Results: An insufficient laryngeal elevation, the amount of pyriform sinus, and vallecular space remnant in addition to the incidence of aspiration were correlated with medullary infarction. Other swallowing parameters were not related to lesion topology. Lip closure dysfunction, decreased tongue movement, increased oral remnant and premature loss were associated with low MMSE scores. A delayed oral transit time were associated with NIHSS scores.

Conclusion: In-coordination of the lip, the tongue, and the oropharynx were associated with the degree of cognitive impairment and the stroke severity rather than with the location of the lesion, whereas incomplete laryngeal elevation and aspiration were predominant in medullary lesions.
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http://dx.doi.org/10.5535/arm.2012.36.3.347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400874PMC
June 2012

Ultrasonography of median nerve and electrophysiologic severity in carpal tunnel syndrome.

Ann Rehabil Med 2012 Feb 29;36(1):72-9. Epub 2012 Feb 29.

Department of Physical Medicine and Rehabilitation, Gangwon-do Rehabilitation Hospital, Chuncheon 200-853, Korea.

Objective: To investigate the correlation of the ultrasonographic wrist-to-forearm median nerve area ratio (WFR) and cross sectional area of median nerve at the wrist (CSA-W) to the electrophysiologic severity in patients with carpal tunnel syndrome (CTS).

Method: One hundred and ten wrists electrophysiologically graded as mild, moderate, and severe CTS and 38 healthy controls underwent ultrasonography of median nerve at the distal wrist crease and mid-forearm. WFR and CSA-W were analyzed according to the severity of CTS.

Results: WFR was 1.12±0.14, 1.91±0.33, 2.27±0.47 and 3.02±0.97 and the CSAs-W was 7.23±1.67 mm(2), 13.51±3.72 mm(2), 14.67±2.93 mm(2), and 18.74±6.01 mm(2) in controls, mild (n=28), moderate (n=46), and severe (n=36) CTS, respectively. CSA-W displayed significant differences between the control and the mild CTS, moderate CTS and severe CTS groups. However, there was no significant difference between mild CTS and moderate CTS groups. WFR revealed significant difference between all groups. The sensitivity and specificity of the WFR in grading the severity of CTS were higher than those of the CSA-W.

Conclusion: Ultrasonography is a useful complementary tool for the evaluation of CTS. Both WFR and CSA-W are highly correlated with severity grade of CTS. However, WFR is superior to CSA-W for diagnosis and grading of the severity of CTS.
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http://dx.doi.org/10.5535/arm.2012.36.1.72DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309326PMC
February 2012

Carpal tunnel syndrome and peripheral polyneuropathy in patients with end stage kidney disease.

J Korean Med Sci 2011 Sep 1;26(9):1227-30. Epub 2011 Sep 1.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea.

This study was designed to identify the causes of the development of carpal tunnel syndrome (CTS) associated with end stage kidney disease (ESKD). A total of 112 patients with ESKD, 64 on hemodialysis (HD) and 48 on peritoneal dialysis (PD), were enrolled. The duration of ESKD and dialysis, the site of the arteriovenous (A-V) fistula for HD, laboratory data such as blood urea nitrogen, creatinine, and beta-2-microglobulin were determined. Clinical evaluation of CTS and electrophysiological studies for the diagnosis of CTS and peripheral neuropathy were performed. The electrophysiological studies showed that the frequency of CTS was not different in the HD and PD groups (P = 0.823) and the frequency of CTS was not different in the limb with the A-V fistula compared to the contralateral limb (P = 0.816). The frequency of HD and PD were not related to beta-2-microglobulin levels, an indicator of amyloidosis. The frequency of CTS did not increase as the severity of the peripheral neuropathy and the duration of ESKD and dialysis increased (P = 0.307). The results of this study do not support that microglobulin induced amyloidosis or placement of an A-V fistula are associated with an increase in CTS.
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http://dx.doi.org/10.3346/jkms.2011.26.9.1227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172662PMC
September 2011

Kinematic analysis of the lumbar spine by digital videofluoroscopy in 18 asymptomatic subjects and 9 patients with herniated nucleus pulposus.

J Manipulative Physiol Ther 2011 May 16;34(4):221-30. Epub 2011 Feb 16.

Bundang Rehabilitation Clinic, JeongJa-Dong, Bundang-Ku, GyeongGi-Do, South Korea.

Objectives: The purpose of this study was to use digital videofluoroscopy to identify motion patterns of the lumbar spine during coronal movement in asymptomatic (normal) subjects and patients with herniated nucleus pulposus (HNP).

Methods: Videofluoroscopic lumbar coronal motion was recorded in 18 asymptomatic volunteers and 9 patients with HNP. Measurements were made while patients bent laterally and rotated toward the right and left from a sitting position and then returned to their original position. Direction and degree of extension in the coronal plane at each motion segment and sacral descent were measured. Through the motion analysis software, the coupled pattern with lateral bending and rotation was analyzed in the asymptomatic subjects and patients with HNP.

Results: Lateral flexion movement was coupled with contralateral extension and ipsilateral sacral descent but with a different rotation pattern. Rotation movement was coupled with ipsilateral extension, ipsilateral sacral descent, and ipsilateral spinous process rotation. Patients with HNP and asymptomatic subjects had similar coupled patterns but differences in amount of motion.

Conclusions: Digital videofluoroscopy showed coupled patterns during the lateral bending and rotation movements.
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http://dx.doi.org/10.1016/j.jmpt.2010.12.011DOI Listing
May 2011

Application of 3-dimensional ultrasonography in assessing carpal tunnel syndrome.

J Ultrasound Med 2011 Jan;30(1):3-10

Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Objectives: The aim of study was to assess the usefulness of 3D ultrasonography (3DUS) in the diagnosis of carpal tunnel syndrome.

Methods: Fifty patients with carpal tunnel syndrome confirmed by electromyography and 37 healthy control participants underwent 3DUS of the wrists. The mean times per participant for the 3DUS examination and review of the 3D volume set were recorded. The cross-sectional area at the proximal carpal tunnel and the maximum swelling point were measured. Data from patients and controls were compared for determination of statistical significance. The accuracy of the 3DUS diagnostic criteria for carpal tunnel syndrome was evaluated using receiver operating characteristic analysis, and changes in the median nerve shape, including the maximum swelling point, were assessed by review of the 3D volume data.

Results: The mean times for examination of a participant and review in each wrist were 56 seconds and 5.7 minutes, respectively. Significant differences were observed in the mean cross-sectional areas of the median nerve between patients and controls. The mean cross-sectional areas ± SD were 16.7 ± 6.7 mm(2) in patients and 8.3 ± 1.9 mm(2) in controls. Using the receiver operating characteristic curve, a cutoff value of greater than 10.5 mm(2) provided diagnostic sensitivity of 84% and specificity of 86%. In 42 of 73 wrists with carpal tunnel syndrome, the median nerve showed fusiform morphologic abnormalities and maximum swelling points.

Conclusions: Our results show that 3DUS could markedly decrease scanning time, and measurement of the median nerve cross-sectional area combined with morphologic analysis using 3DUS is a promising supplementary method for the diagnosis of carpal tunnel syndrome.
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http://dx.doi.org/10.7863/jum.2011.30.1.3DOI Listing
January 2011

Anatomical and electrophysiological myotomes corresponding to the flexor carpi ulnaris muscle.

J Korean Med Sci 2010 Mar 17;25(3):454-7. Epub 2010 Feb 17.

Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea.

This study was designed to investigate the incidence of lateral root of the ulnar nerve through cadaveric dissection and to analyze its impact on myotomes corresponding to the flexor carpi ulnaris (FCU) assessed by electrodiagnostic study. Dissection of the brachial plexus (BP) was performed in 38 arms from 19 cadavers, and the connecting branches between the lateral cord and medial cord (or between lateral cord and ulnar nerve) were investigated. We also reviewed electrodiagnostic reports from January 2006 to May 2008 and selected 106 cases of single-level radiculopathy at C6, C7, and C8. The proportion of abnormal needle electromyographic findings in the FCU was analyzed in these patients. In the cadaver study, branches from the lateral cord to the ulnar nerve or to the medial cord were observed in 5 (13.1%) of 38 arms. The incidences of abnormal electromyographic findings in the FCU were 46.2% (36/78) in C7 radiculopathy, 76.5% (13/17) in C8 radiculopathy and 0% (0/11) in C6 radiculopathy. In conclusion, the lateral root of the ulnar nerve is not an uncommon anatomical variation of the BP and the FCU commonly has the C7 myotome. Needle EMG of the FCU may provide more information for the electrodiagnosis of cervical radiculopathy and brachial plexopathy.
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http://dx.doi.org/10.3346/jkms.2010.25.3.454DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2826750PMC
March 2010

Needle electrode insertion into the tibialis posterior: a comparison of the anterior and posterior approaches.

Arch Phys Med Rehabil 2008 Sep;89(9):1816-8

Department of Rehabilitation Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.

Objectives: To analyze and compare the safety of the anterior and posterior approaches for needle electrode placement and to examine the method for inserting the needle electrode using the anterior approach.

Design: Cross-sectional study.

Setting: University hospital.

Participants: Lower-extremity radiographs and magnetic resonance images of 22 patients (13 men, 9 women).

Interventions: Not applicable.

Main Outcome Measure: Measurement of lower-extremity radiographs and magnetic resonance imaging.

Results: The anterior approach offers the advantage of a larger safe window for needle insertion into the upper third of the leg than the posterior approach. No significant differences were observed between the anterior and posterior approaches in terms of safety of needle insertion into the midpoint. The safe zone of the overlying skin for needle insertion was found to be approximately 40% to 80% of the width of the tibia away from the lateral margin of the tibia shaft on the upper third of the leg and 32% to 58% of the width of the tibia at the midpoint of the leg in the anterior approach.

Conclusions: The method suggested in this article can be used for needle electromyography and deserves more widespread use in clinical practice.
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http://dx.doi.org/10.1016/j.apmr.2008.01.027DOI Listing
September 2008

The effect of anatomical variation of the sural nerve on nerve conduction studies.

Am J Phys Med Rehabil 2008 Jun;87(6):438-42

Department of Rehabilitation Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Objective: To investigate the types of sural nerve formation through cadaver study, and to evaluate the relationship between anatomical variation and nerve conduction study (NCS).

Design: We examined the formation of the sural nerve in 26 legs from cadavers. Sural NCS was performed in 60 legs of healthy adults to evaluate the influence of anatomical variation on NCS.

Results: The sural nerve was formed by the anastomosis of the MSCN and LSCN in the calf in 20 out of 26 legs (76.9%). The sural nerve was a direct continuation of the MSCN in four (15.4%) cases, and there was no communication between the MSCN and LSCN in two cases (7.7%). The anastomoses were located in the middle and distal third of the leg in 9 and 11 out of 20 legs, respectively. Separate sensory nerve action potentials of the MSCN and LSCN were recorded in 4 out of 60 legs (6.7%) during NCS of the sural nerve, and a double peak was recorded in each of these legs.

Conclusions: Because the sural nerve formation is highly variable, the possibility of anatomical variation should be considered when the sural sensory nerve action potential is of low amplitude and disproportionate to the neurologic evaluation.
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http://dx.doi.org/10.1097/PHM.0b013e318174e569DOI Listing
June 2008

Amplitude ratio of ulnar sensory nerve action potentials in segmental conduction study: reference values in healthy subjects and diagnostic usefulness in patients with ulnar neuropathy at the elbow.

Am J Phys Med Rehabil 2008 Aug;87(8):642-6

Department of Rehabilitation Medicine, Korea University Anam Hospital, Korea University College of Medicine, 5 ga 126-1, Anam-dong, Sungbuk-gu, Seoul, 136-705, Korea.

Objective: To determine normal values for the amplitude ratio of sensory nerve action potential (SNAP) from an ulnar sensory segmental nerve conduction study, and to the evaluate usefulness in the diagnosis of mild-degree ulnar neuropathy at the elbow (UNE).

Design: Segmental sensory conduction study of the ulnar nerve was performed in 71 healthy subjects. Peak latency and baseline to peak amplitudes were measured. The amplitude ratio of below-elbow to wrist (BE/W) stimulations and above-elbow (AE) to below-elbow stimulations (BE) were calculated. Normal cutoff values were obtained by subtracting 2 SD from the mean value, and these values were applied to 22 symptomatic UNE cases. The amplitude ratio was also obtained in six subjects with C8 radiculopathy.

Results: The amplitude ratios of BE/W and AE/BE were 0.61 +/- 0.08 and 0.82 +/- 0.08, respectively. The cutoff value of BE/W was 0.45, and that of AE/BE was 0.65. The amplitude ratio of BE/W showed a weak correlation to the length of the forearm segment (r = -0.25, P < 0.05). Five of the 22 UNE patients revealed only reduced amplitude ratios of SNAP across the lesion, whereas all the patients with C8 radiculopathy showed normal amplitude ratios of ulnar SNAP.

Conclusions: The amplitude ratio of ulnar SNAPs may be useful in the diagnosis of mild ulnar neuropathy with only sensory symptoms and normal segmental motor conduction.
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http://dx.doi.org/10.1097/PHM.0b013e31816de327DOI Listing
August 2008

Compound nerve action potential of common peroneal nerve and sural nerve action potential in common peroneal neuropathy.

J Korean Med Sci 2008 Feb;23(1):117-21

Department of Rehabilitation Medicine, Korea University College of Medicine, Seoul, Korea.

To enhance the accuracy for determining the precise localization, the findings of the compound nerve action potentials (CNAPs) of the common peroneal nerve (CPN) were investigated in patients with common peroneal mononeuropathy (CPM) in the knee, and the sural sensory nerve action potentials (SNAPs) were also analyzed. Twenty-five patients with CPM in the knee were retrospectively reviewed. The findings of the CNAPs of the CPN recorded at the fibular neck and the sural SNAPs were analyzed. The lesion was localized at the fibular head (abnormal CNAPs) and at or distal to the fibular head (normal CNAPs). Seven patients were diagnosed as having a lesion at or distal to the fibular neck, and 18 cases were diagnosed as having a fibular head lesion. The sural SNAPs were normal in all the cases of lesion at or distal to the fibular neck. Among 18 cases of fibular head lesion, the sural SNAPs were normal in 7 patients: two cases of conduction block and 5 cases of mild axon loss. Eleven patients showed abnormal sural SNAPs. Of those, 9 cases were severe axon loss lesions and 2 patients were diagnosed as having severe axon loss with conduction block. The recording of the CNAPs may enhance precise localization of CPM in the knee. Moreover, the sural SNAPs could be affected by severe axonal lesion at the fibular head.
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http://dx.doi.org/10.3346/jkms.2008.23.1.117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526500PMC
February 2008

Frequency and severity of carpal tunnel syndrome according to level of cervical radiculopathy: double crush syndrome?

Clin Neurophysiol 2006 Jun;117(6):1256-9

Department of Rehabilitation Medicine, Korea University College of Medicine, 126-1 Anam Dong 5 Ga, Sungbuk Gu, Seoul 136-705, South Korea.

Objective: The double crush hypothesis (DC) proposes that a proximal lesion along an axon predisposes it to injury at a more distal site along its course through impaired axoplasmic flow. The frequency and severity of carpal tunnel syndrome (CTS) according to the level of cervical radiculopathy were investigated to evaluate the hypothesis of DC.

Methods: The frequency of CTS was investigated in 277 patients with C6, C7 or C8 radiculopathies and correlation between CTS and radiculopathy level was determined. We also investigated whether the degrees of abnormal sensory responses were more severe in C6, C7 radiculopathies and whether motor responses were more severe in C8 radiculopathy.

Results: Thirty-nine patients were diagnosed with CTS and concomitant cervical radiculopathy at the C6, 7, or C8 root levels. The frequency of coexisting CTS was not statistically different according to the level of radiculopathy. The electrophysiologic results revealed no significant correlation between median sensory parameters and C6, C7 cases, and no relationship was observed between median motor responses and C8 radiculopathy.

Conclusions: The frequency and electrophysiologic data of CTS analyzed according to cervical radiculopathy level do not support a neurophysiological explanation.

Significance: Based on this study, the DC hypothesis could not be supported.
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http://dx.doi.org/10.1016/j.clinph.2006.02.013DOI Listing
June 2006

Reference values of fractionated neurography of the ulnar nerve at the wrist in healthy subjects.

Clin Neurophysiol 2005 Dec 10;116(12):2853-7. Epub 2005 Oct 10.

Department of Rehabilitation Medicine, Korea University, College of Medicine, Seoul, South Korea.

Objective: This study is designed to derive a normative database for nerve conduction values of the ulnar nerve in the wrist.

Methods: Ulnar nerve study at the wrist (UNSW) was performed in 204 hands of 102 control subjects. The UNSW was composed of motor and sensory tests. Motor UNSW was done with first dorsal interosseous muscle recording. Sensory UNSW was performed antidromically with fifth finger recording. The 3 stimulation points were 2 cm proximal to the pisiform, just lateral to pisiform, and 3 cm distal to the pisiform.

Results: Mean latency differences in the proximal and distal segments were 0.4 +/- 0.1 and 0.5 +/- 0.1 ms in motor UNSW and 0.4 +/ -0.1 and 0.5 +/- 0.1 ms in sensory UNSW. The 95th percentile values for motor and sensory UNSW were 0.5 ms in the proximal segment and 0.7 ms in the distal segment.

Conclusions: When the 95-percentile value was considered as the normal upper limit, the criteria of abnormality for motor and sensory UNSW were greater than 0. 5 ms in the proximal segment and greater than 0.7 ms in the distal segment.

Significance: The normative values of UNSW may be useful in screening for ulnar neuropathy at the wrist.
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http://dx.doi.org/10.1016/j.clinph.2005.08.002DOI Listing
December 2005
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