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Chungcheongbuk-do, Republic of Korea

Tel +82-43-713-8000 www.khidi.or.kr

REHABILITATIONSmartcare

Contents

1

2

3

4

5

Rehabilitation Therapy in Korea 2

1 Infrastructure of Rehabilitation Therapy in Korea 2

2 Rehabilitation Medicine in Korea 5

Why Korea? 8

1 Neurorehabilitation 8

2 Spinal Cord Rehabilitation 22

3 Pediatric Rehabilitation 30

4 Cancer Rehabilitation 37

5 Cardiac Rehabilitation 45

6 Pulmonary Rehabilitation 55

7 Robot-Assisted Rehabilitation 60

Successful Clinical Cases of Rehabilitation

Therapy in Korea 71

1 Spinal Cord Rehabilitation 71

2 Pediatric Rehabilitation 72

3 Cancer Rehabilitation 74

4 Cardiac Rehabilitation 76

5 Pulmonary Rehabilitation 78

Domestic Medical Process for

Foreign Patients 80

Rehabilitation-Specialized

Medical Institutions in Korea 81

2 3

Rehabilitation Therapy in Korea Smart Care - Rehabilitation

(2) Related Academic Societies

There is a variety of related academic societies in the rehabilitation field, and they are active in

research and development in their each specialized field.

(3) Academic Symposiums

Domestic regular academic symposiums are held twice a year and provide various lecture

courses, through which participants can share their research results and learn more about the

rehabilitation medicine. For international academic symposiums, the first Korea-Japan rehabili-

tation medicine symposium was held in 2002 in Gyeongju, where 387 people from Korea and

141 people from Japan participated for successful interaction between Korean and Japanese re-

habilitation societies. The international rehabilitation medicine symposium first held in 2001 con-

Korean Association of Electrodiagnostic Medicine

Korean Society for NeuroRehabilitation

Korean Society of Pediatric Rehabilitation and Developmental Medicine

Korean Academy of Neuromusculoskeletal Sonography (KANMS-SONO)

Korean Dysphagia Society

Korean Society of Lymphedema

Korean Spinal Cord Society

Korean Academy of Geriatric Rehabilitation Medicine

Korean Academy of Foot & Ankle Medicine

Korean Academy of Sports Science and Exercise Medicine

Korean Academy of Cardio-pulmonary Rehabilitation Medicine

Korean Association of Pain Medicine

Korean Society for Prosthetics and Orthotics

Related Academic Societies

Rehabilitation Therapy in Korea1Rehabilitation

(1) Rehabilitation-Specialized Medical Staff System

As of 2017, 2,113 rehabilitation medicine specialists are engaged in medical care and research,

and there are about 84 training hospitals nationwide. A total of about 84 nationwide high-class

general hospitals and training hospitals at the level of general hospitals practicing comprehensive

rehabilitation therapy provide specialized rehabilitation therapies.

Distribution of Major National Rehabilitation Medical Institutions (University hospitals and training hospitals)

Figure 1

Infrastructure of Rehabilitation Therapy in Korea1

47개(55.9%)

Seoul·Incheon·Gyeonggi

47 hospitals

Gangwon

4 hospitals

Busan·Ulsan·Gyeongnam

10 hospitals

Jeju 1 hospitals

Daejeon·Chungcheong

9 hospitals

Gwangju·Jeolla

7 hospitals

Daegu·Gyeongbuk

6 hospitals

4 5


Annals of Rehabilitation MedicineFigure 3

Clinical practice of rehabilitation medicine in Korea involves experts from various medical fields,

such as rehabilitation medicine specialist, rehabilitation nurse, physical therapist, occupational

therapist, speech therapist, rehabilitation psychotherapist, and rehabilitation social worker. A com-

prehensive rehabilitation therapy system has been established to minimize a risk of developing

disabilities by achieving goals that are set according to an individual’s recovery and prognosis.

The clinical level of rehabilitation medicine in Korea is world-class in regard to evaluation of

research papers and treatment effects. Various effective treatments are carried out using the

latest diagnostic methods, treatment methods and development of advanced treatment device in

each medical field. In all fields, the state-of-the-art imaging equipment, advanced special imaging

techniques, and latest treatment devices are used before and after the treatment to improve

the effectiveness of the therapy. Recently, therapeutic applications using advanced equipment,

such as robots, have been applied to patients with neurological damage, spinal cord injury, and

cerebral palsy, and the world-class medical treatment system has been established in Korea in

all medical fields.

Rehabilitation Medicine in Korea2

tinued and the 4th international symposium was held in Seoul in 2007, where over 1,500 foreign

participants from 74 countries and 750 domestic rehabilitation medicine researchers attended.

This symposium composed of invited lectures of more than 180 world-renowned rehabilitation

medicine specialists and presentation of about 1,150 published papers by domestic and overseas

research teams, making it the most successful event held in the rehabilitation medicine field.

(4) Publication of the Journal

When the journal was first published in April 1997, it was published twice a year, and since

1991, it had been published four times a year, which changed to six times a year in 1997. The

journal has been registered in the Korea Academic Foundation since 2002. It was first published

in English in December 2010, and the name of the journal was changed to “Annals of rehabili-

tation medicine” in June, 2011 (Volume 35, Issue 5). It was listed on Scopus in 2012 and was

listed on PubMed Central in 2012. The journal publishes various research papers on neurological

diseases, musculoskeletal diseases, electrical diagnoses, spinal cord injuries, etc. and a total of

3,930 papers have been published as of 2017.

The 4th International Rehabilitation Medicine SymposiumFigure 2

6 7


In the cancer rehabilitation field, studies have been published, and they demonstrate the effects of

rehabilitation therapy that yields the best functional outcomes in various cancer types. Also, the global

attention has been drawn by conducting innovative researches that include papers that showed an

improved outcome of cancer rehabilitation by using the mobile environment.

In the case of cardiac pulmonary rehabilitation, it is leading the way in the international treat-

ment of the disease by identifying the characteristics according to the characteristics of each

disease, evaluating using advanced equipment, and leading the research on treatment effects. It

also provides global education to various countries on domestic clinical guidelines and research

achievements for practice.

In the field of robot-assisted rehabilitation, it was found to be effective in improving upper limb

function, muscular strength, and ability to perform daily activities in stroke patients. The lower

limb robot-assisted rehabilitation treatment has advantage and therapeutic effect different from

the gait therapy performed by the physical therapist and was identified to have a significant thera-

peutic effect in subacute stroke patients, leading to its application in the latest treatment.

800

600

400

200

0

| Source | Korean Academy of Rehabilitation Medicine (2018)

6798 104

215

339

495

695728710

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

265

No. of Yearly Korean Rehabilitation Medicine Research Papers PresentedFigure 5

(1) Research Achievements of Rehabilitation Therapy in Korea by Field

Korea ‘s rehabilitation medicine has been producing the world-class research results in each

field so far. In the field of neurorehabilitation, the radiological research on the mechanism of

functional recovery of various brain diseases and research on the therapeutic effect through ad-

vanced treatment, such as brain stimulation and virtual reality, are actively carried out. Through

such achievements, the clinical guidelines for comprehensive rehabilitation therapy are published

every four years, leading to the standardized application of the new treatments. The annual num-

ber of papers published in international journals by Korean rehabilitation specialists is as follows.

In the field of spinal cord injuries, there have been leading studies on the latest treatments,

such as stem cell therapy, the effects of various rehabilitation treatments, and the prognosis of

spinal cord injury. In the field of pediatric rehabilitation, various studies on diagnosis and treatment

of cerebral palsy have been published, and despite the increase in the prevalence of prematurity

and low birth weight in Korea, the number of children with cerebral palsy has been reported to be

decreased in the last five years due to the active application of the rehabilitation therapy, proving

the high-level medical system in Korea.

Fields of Rehabilitation MedicineFigure 4

PediatricRehabilitation

Musculoskel-etal Rehabili-

tation

CancerRehabilitation

Cardiopul-monary

Rehabilitation

ElderlyRehabilitation

Neurological Rehabilitation

AmputeeRehabilitation

Spinal Injury Rehabilitation

Rehabilitation medicine

8 9

Why Korea? Smart Care - Rehabilitation

disabilities even after the initial appropriate treatment. Neurorehabilitation is a medical field that

makes efforts to minimize the disabilities that may arise after the occurrence of such brain disor-

ders.

Depending on the type and extent of brain disease, it is known that about 85% of stroke pa-

tients are left with functional impairment. In addition, the disability that occurs after brain disease

is highly diverse and can lead to motor impairment, sensory impairment, pain, cognitive impair-

ment, speech disorder, dysphagia, emotional change, and visual field disorders. These can make

it difficult for patients to return to and maintain social life and lead to loss of function as a family

member.

Rehabilitation goals of patients with brain disorders who gain various disabilities are to prevent

the recurrence of brain disorders and manage complications that may arise from brain disorders

through prevention, early diagnosis, and treatment so that patients recover functions as much as

possible, carry out daily life activities independently and maintain meaningful lives as members

of the family and society.

(2) Diagnosis Method and Advanced Equipment

Evaluation of stroke patients should be made on the basis of neurological impairment, disabil-

ity, and handicap. In addition, the evaluation of the function integrates various aspects such as

motor and sensory function, cognition, language, ambulation, and dysphagia and also includes

evaluation of various disabilities such as dependent activities of daily living, emotional disorders,

disability of returning to society, and loss of role as a family member.

The goal of neurorehabilitation is to minimize the deterioration of functions and help patients to

perform functions as independently as possible so that they can return to their home and family

as well as the society and live meaningful lives.

(3) Overview of the Rehabilitation Method

Neurorehabilitation therapy is performed in terms of function to minimize disability by achieving

goals set according to individuals’ recovery and prognosis. It involves rehabilitation medicine spe-

Why Korea?2Rehabilitation

(1) Introduction of Disease

Brain disorders treated in Neurorehabilitation are diverse, including stroke, traumatic brain in-

jury, brain tumor, encephalitis, movement disorders such as Parkinson’s disease, and dementia.

However, a common feature of these brain disorders is that in many cases the patient can have

| Source | 10-year follow-up study report on factors related to level of long-term rehabilitation function in stroke patients (Chronic Disease Management Division, Center for Disease Prevention, Korea Centers for Disease Control and Prevention, 2017)

•�Reperfusion and Deterioration Prevention

- Pharmacological treatment- Surgical treatment- Early rehabilitation treatment

•�Function Recovery

- Comprehensive rehabilitation treatment

- Recurrence prevention

•Recurrence Prevention

•Function Maintenance

Comprehensive Rehabilitation Medical Services provided to a patient who had strokeFigure 6

Acute Phase Subacute Phase Chronic Phase

- At the right time- Appropriate- -Comprehensive

Acute Phase Treatment and Rehabilitation

- Reduction of sequelae- Functional independence

Subacute Rehabilitation Treatment

- Improvement of the quality of life

Stroke Patient

- Alleviation of support burden- Improvement of support level

Family

- Alleviation of economic burden

Society

Stroke Occurrence

1 Neurorehabilitation

10 11


Composition of the Neurorehabilitation TeamFigure 7

Patient withBrain Disorder and

Caregiver

Rehabilitation Social Worker

RehabilitationPsychologist

Speechlanguage

Occupational Therapist

PhysicalTherapist

Rehabilitation Nurse

Neurological Rehabilitation

Specialist

(4) Research Accomplishments Made in Korea

The statistics of the number of papers on neurorehabilitation published by Korean rehabilitation

medicine physicians in recent 10 years are as follows. The number of papers in the field of neu-

rorehabilitation increased by about 10 times from 22 in 2008 to 201 in 2017.

cialist, rehabilitation nurse, physical therapist, occupational therapist, speech-language therapist,

rehabilitation psychologist, and rehabilitation social worker, who cooperate to minimize the pa-

tient’s disability with a focus on the patient and family.

Neurorehabilitation therapy is performed for each of the following functional disabilities be-

cause brain disorders can cause various functional impairments:

A. Physical Therapy

It is a treatment to help the recovery of damaged CNS and use the remaining body functions to

carry out daily life activities and walk, and it involves general therapies such as passive and active

joint range of motion exercises, neuromuscular stimulation therapy, functional electric stimulation

therapy, and functional training.

B. Occupational Therapy

It trains patients for basic daily activities such as eating, cleansing, and dressing and further train

them so that they can use complex tools and carry out social activities by themselves.

C. Cognitive Therapy

It evaluates cognitive, emotional, and behavioral changes that are likely to be overlooked after

stroke and provides relative information. Also, it provides computerized cognitive therapy and

various cognitive behavioral therapy for restoration of function.

D. Speech and Language Therapy

It is a rehabilitation therapy that evaluates communicational disability such as aphasia and dys-

arthria, appropriately trains patients for speaking, listening, writing, and reading and utilizes intact

functions for communication.

E. Dysphagia Therapy

Dysphagia can cause serious complications such as aspiration pneumonia. It uses videofluoro-

scopic swallowing study to assess the accurate status of swallowing function to provide dietary

modification, exercise promotion, compensation, and electrical stimulation treatments to help

patients have foods safely.

Number of Papers Published by Korean Researchers in International JournalsFigure 8

200

150

50

100

02008 2009 2010 2011 2012 2013 2014 2015 2016 2017

22

49 45

70

124138

180201

188

91

Sum 1,108


12 13


A. DTI study in stroke patients (Jang SH et al, Stroke 2013), B. DTI study in patients with a traumatic brain injury (Jang SH et al, Front Neurol 2018)

ter. Studies in the field of neurorehabilitation using DTI and diffusion tensor tractograpy (DTT) to

evaluate brain white matter 4) have been reported.

3 Research using Positron Emission Tomography (PET) and functional Near Infrared Spec-

troscopy (fNIRS) 5)

Studies using PET, which can analyze the brain metabolisms, and fNIRS, which can measure the

changes of real-time cortical blood flow according to the function have been reported recently 6).

4) Jang SH, Kwon YH. A Review of Traumatic Axonal Injury following Whiplash Injury As Demonstrated by Diffusion Tensor Tractography. Front Neurol 2018;9:57

5) Kim YW, Kim HS, An YS. Statistical mapping analysis of brain metabolism in patients with subcortical aphasia after intracerebral hem- orrhage: a pilot study of F-18 FDG PET images. Yonsei Med J 2012;53:43-52.

6) Hong KS, Bhutta MR, Liu X, Shin YI. Classification of somatosensory cortex activities using fNIRS. Behav Brain Res 2017;333:225-34.

Research using DTIFigure 10

A. B.

Research using fMRIFigure 9

A. Task-based fMRI study in stroke patients (Jang SH et al, Neuroreport 2002), B. Resting-state fMRI study in stroke patients (Park CH et al, Stroke 2011)

A. B.

A. Research on Mechanism of Rehabilitation Therapy of Patients with Brain Disorders

In the neurorehabilitation, it is important to study the mechanism of brain function recovery us-

ing functional neuroimaging in order to accurately predict the functional recovery in patients with

brain disorders and set appropriate goals to enhance the effectiveness of rehabilitation therapy.

1 Research using functional Magnetic Resonance Imaging (fMRI) 1)

It has been continuously reporting research results in the field of neurorehabilitation in Korea for

more than 20 years. In addition to task-based fMRI, which mainly evaluates the brain activity area

by function, it has published research results 2) that use resting-state fMRI to evaluate functional

neural network in high impact journals.

2 Research using Diffusion Tensor Imaging (DTI) 3)

In order to understand brain function, it is important to analyze gray matters as well as white mat

1) Jang SH, Kim YH, Cho SH, Lee JH, Park JW, Kwon YH. Cortical reorganization induced by task-oriented training in chronic hemiplegic stroke patients. Neuroreport 2003;14:137-41.

2) Park CH, Chang WH, Ohn SH, et al. Longitudinal changes of resting-state functional connectivity during motor recovery after stroke. Stroke 2011;42:1357-62

3) Jang SH, Chang CH, Lee J, Kim CS, Seo JP, Yeo SS. Functional role of the corticoreticular pathway in chronic stroke patients. Stroke 2013;44:1099-104.

A. Study using PET (Kim YW et al, YMJ 2012), B. Study using fNIRS (Hong KS et al, Behav Brain Res 2017)

Research using PET and fNIRSFigure 11

A. B.

14 15


B. Non-Invasive Brain Stimulation (NIBS)

In neurorehabilitation, NIBS, which can directly modulate the excitability of brain without surgi-

cal treatment that causes functional impairment, is a new treatment method that can improve the

function of patients with brain disorder. NIBS is a new and safe treatment that can treat various

symptoms caused by brain disorders through local stimulation of brain over scalp. There are two

common methods of NIBS: repetitive transcranial magnetic stimulation (rTMS) and transcranial

direct current stimulation (tDCS).

1 Repetitive transcranial magnetic stimulatio (rTMS) 8)

rTMS is a treatment method that uses a magnetic coil to generate a magnetic field that lasts for

a short time on the outside of the scalp and transmits the fluctuating energy of the magnetic field

wave to the cerebral cortex to stimulate neurons 9). A Korean neurorehabilitation research team has

reported the clinical effect of high-frequency rTMS in stroke patients for the first time in the world,

and further research results have been continuously reported 10) to lead the clinical use of rTMS.

8) Kim YH, You SH, Ko MH, et al. Repetitive transcranial magnetic stimulation-induced corticomotor excitability and associated motor skill acquisition in chronic stroke. Stroke 2006;37:1471-6.

9) Chang WH, Kim YH, Bang OY, Kim ST, Park YH, Lee PK. Long-term effects of rTMS on motor recovery in patients after subacute stroke. J Rehabil Med 2010;42:758-64.

10) Chang WH, Kim YH, Yoo WK, et al. rTMS with motor training modulates cortico-basal ganglia-thalamocortical circuits in stroke pa-tients. Restor Neurol Neurosci 2012;30:179-89.

A. Brain MRI B. DTI&DTT

C. MEPs D.fMRI

Research using Multimodal NeuroimagingFigure 12

| Source | Chang WH et al. Neuroreport 2009

4 Research using Multimodal Neuroimaging 7)

Various functional neuroimaging techniques have different strengths and weaknesses. Therefore,

it is important to understand the brain function by conducting studies using multimodal neuroim-

aging.

In Korea, researches using multimodal neuroimaging are continuously reported.

7) Chang WH, Kim YB, Ohn SH, Park CH, Kim ST, Kim YH. Double decussated ipsilateral corticospinal tract in schizencephaly. Neurore-port 2009;20:1434-8.

A. World’s first report of clinical effect of high-frequency rTMS in stroke patients (Kim YH et al, Stroke 2006), B. Study on long-term effect of high-frequency rTMS in stroke patients (Chang WH et al, J Rehabil Med 2010), C. Study on mechanism of rTMS (Chang WH et al, Restor Neurol Neurosci 2012)

Research using rTMSFigure 13

A. B. C.

16 17


1 Robot-Assisted Rehabilitation Therapy for Upper Limb and Hand Motor Function 13)

Korea is involved in research using the conventional upper limb rehabilitation robots and actively par-

ticipates in domestic development of the upper limb rehabilitation robot. Studies on development

and effectiveness 14) of a new upper limb rehabilitation robot that overcomes the shortcomings

of the conventional upper limb rehabilitation robot have been reported.

2 Robot Rehabilitation Therapy for Gait Function 15)

Korea is involved in research using the conventional rehabilitation robots for gait function and ac-

tively participates in domestic development of the rehabilitation robot for gait function. Studies on

13) Shin JH, Park G, Cho DY. Cognitive-Motor Interference on Upper Extremity Motor Performance in a Robot-Assisted Planar Reaching Task Among Patients With Stroke. Arch Phys Med Rehabil 2017;98:730-7.

14) Kim GW, Won YH, Seo JH, Ko MH. Effects of newly developed compact robot-aided upper extremity training system (Neuro-X(R)) in patients with stroke: A pilot study. J Rehabil Med 2018;50:607-12.

15) Chang WH, Kim MS, Huh JP, Lee PK, Kim YH. Effects of robot-assisted gait training on cardiopulmonary fitness in subacute stroke patients: a randomized controlled study. Neurorehabil Neural Repair 2012;26:318-24.

A. World’s first report on tDCS-induced cognitive imporvement effect in stroke patients (Ohn SH et al, NeuroReport 2006), B. Study on long-term effect of tDCS in stroke patients (Chang MC et al, Brain Stimul 2015)

Research using tDCSFigure 14

A. B.

2 Transcranial direct current stimulation (tDCS) 11)

tDCS stimulates cerebral cortex by attaching electrodes to the scalp and inducing weak current,

which activates or suppresses cortex according to the polarity of the current to achieve the desired

treatment effect. A Korean neurorehabilitation research team reported tDCS-induced cognitive en-

hancement in stroke patients for the first time in the world 12), and study results have been contin-

uously reported.

C. Robot-Assisted Rehabilitation Therapy

Through using robots in neurorehabilitation therapy, it can repeatedly perform therapeutic

tasks, and by combining other technologies, it can encourage patients’ participation, leading to

enhancement of understanding of functional exercise learning. In this leading field, Korea’s neu-

rorehabilitation is paving its way to the world-class level.

11) Ohn SH, Park CI, Yoo WK, et al. Time-dependent effect of transcranial direct current stimulation on the enhancement of working memory. Neuroreport 2008;19:43-7.

12) Chang MC, Kim DY, Park DH. Enhancement of Cortical Excitability and Lower Limb Motor Function in Patients With Stroke by Tran-scranial Direct Current Stimulation. Brain Stimul 2015;8:561-6.

Research on Robot-assisted Rehabilitation Therapy for Upper Limb and Hand Motor Function

Figure 15

A. Report on effect of upper limb robot-assisted rehabilitation therapy developed overseas (Shin JH et al, Arch Phys Med Rehabil 2017), B. Report on effect of upper limb robot-assisted rehabilitation therapy developed domestically (Kim GW et al, J Rehabil Med 2018)

A. B.

18 19


(5) Strengths of Korean Rehabilitation Medicine

The Korean version of the Modified Barthel Index (K-MBI), which measures the independency

of activities of daily living as the most important goal of neurorehabilitation, and the US National

Institutes of Health Stroke Scale Guideline have been developed for standardization of the neu-

rorehabilitation field in Korea, and the structured evaluation is carried out based on such stand-

ardization.

In 2009, “Clinical Practice Guideline for Stroke Rehabilitation in Korea” was reported, and

standard guidelines for stroke rehabilitation are periodically revised by publishing the 2nd revision

(“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012”) and the 3rd revision (“Clini-

cal Practice Guideline for Stroke Rehabilitation in Korea 2016”).

Such periodic revisions of the rehabiliation guidelines are considered as requirement in the con-

stantly developing field of neurorehabilitation, and the four-year cycle of the treatment guideline

revision shows that Korea is at the top of the global medical system. The leading standardization of

functional evaluation and rehabilitation therapy in Korea has improved the nationwide level of neu-

A. Report on effect of upper limb robot-assisted rehabilitation therapy developed overseas (Chang WH et al, Neurorehabil Neural Repair 2012), B. Report on effect of walk-assisting robot developed domestically (Lee HJ et al. IEEE Trans Neural Syst Rehabil Eng 2017)

Robot RehabilitationTherapy for GaitFigure 16

A. B.

develop-ment and effectiveness of a new rehabilitation robot that overcomes the shortcomings of

the conventional rehabilitation robot for gait function 16) have been reported.

D. Virtual Reality (VR) 17)

Recently, programs using virtual reality have been developed for therapeutic purposes in the

field of neurorehabilitation, and virtual reality programs provide reality-like environment or even a

sense of augmented reality for re-learning of patients with brain disorder. In addition, its impor-

tance in neurorehabilitation has been emphasized recently because it can stimulate rehabilitation

therapy using various feedback mechanisms. In Korea, which is a strong IT country, many studies

on neurorehabilitation using virtual reality have been reported 18).

16) Lee HJ, Lee S, Chang WH, et al. A Wearable Hip Assist Robot Can Improve Gait Function and Cardiopulmonary Metabolic Efficiency in Elderly Adults. IEEE Trans Neural Syst Rehabil Eng 2017;25:1549-57

17) Kim DY, Ku J, Chang WH, et al. Assessment of post-stroke extrapersonal neglect using a three-dimensional immersive virtual street crossing program. Acta Neurol Scand 2010;121:171-7.

18) Shin JH, Bog Park S, Ho Jang S. Effects of game-based virtual reality on health-related quality of life in chronic stroke patients: A randomized, controlled study. Comput Biol Med 2015;63:92-8.

A. Evaluation on utilization ability of domestically developed VR (Kim DY et al, Acta Neurol Scand 2010), B. Report on effect of domestically developed VR-using rehabilitation therapy (Kim GW et al, Comput Biol Med 2015)

Virtual Reality (VR) ResearchFigure 17

B. A.

20 21


Trend of an Increase in the Number of Neurorehabilitation SpecialistFigure 18

| Source | 10th anniversary of Korea Society for Neurological Rehabilitation Society

800

600

400

200

02007 2008 2009 2010 2011 2012 2013 2014 2015 2016

156 168218

273

595 606677 688

550615

Neu

rolo

gica

l Reh

abili

tatio

n Sp

ecia

lists

(num

ber)

(Year)

rorehabilitation medical care and has established an excellent neurorehabilitation medical system.

In addition, the number of rehabilitation medicine specialists who specialize in neurorehabili-

tation in Korea has steadily increased over the past 10 years, and currently, there are about 600

Neurorehabilitation specialists in practice.

As of 2018, 77 training hospitals nationwide are training neurorehabilitation specialists, and in

addition to 77 training hospitals, many neurorehabilitation hospitals nationwide are actively prac-

ticing rehabilitation therapy for patients with brain disorders. Neurorehabilitation varies according

to the characteristics of the patient, and depending on the circumstances, patients may receive

ambulatory treatment.

Neurorehabilitation in Korea provides the best customized rehabilitation therapy based on a

comprehensive evaluation, and the duration of rehabilitation is also different depending on the

patient. According to the recently reported Korean studies23), the therapeutic effects in 1,162

patients who received hospitalization rehabilitation treatment at tertiary hospitals showed that

97.6% of the patients showed disabilities 16.3 days after the occurrence of stroke, but after the

intensive hospitalization rehabilitation treatment, only 68.2% reported of having disabilities after

six months. In addition, disabilities were found to be decreased in 73.2% of the patients, which

was significantly effective in stroke patients who received intensive hospitalized rehabilitation

therapy compared with the patients who did not. Such stroke disability-reducing effect is a good

indicator of excellence of neurorehabilitation in Korea.

Degree of Decrease in the Disability in Stroke Patients after Intensive Hospitalization Rehabilitation Therapy

Figure 19

Non-Intensive Rehabilitation Group








0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Tota

l Stro

ke

Patie

nts

Grad

e 1

Disa

bilit

yGr

ade

2Di

sabi

lity

Grad

e 3

Disa

bilit

yGr

ade

4Di

sabi

lity

Grad

e 5

Disa

bilit

yGr

ade

6Di

sabi

lity

NoDi

sabi

lity

Intensive Rehabilitation Group








4.7% 43.3% 52.0%

3.1% 23.7% 73.2%

Worsening Maintenance Improvement

39.8% 60.2%

48.7% 51.3%

7.6% 19.0% 73.5%

5.1% 10.7% 84.2%

4.1% 9.6% 86.3%

7.9% 9.2% 82.9%

4.2% 9.9% 85.8%

6.2% 6.2% 87.6%

4.0% 7.1% 88.9%

3.7% 8.5% 87.8%

5.1% 9.2% 85.7%

6.1% 12.1% 81.8%

5.4% 94.6%

10.7% 89.3%

22 23


2 Radiological Examination of Patients with Fractures and Dislocation of Cervical Spine C5/C6

Figure 20

CT MRISimple X-ray

MRI and Spinal Nerve Fiber Map in Patients with Spinal Cord InjuryFigure 21

Recently, diffuse tensor imaging (DTI) of MRI has been used in an attempt to identify the de-

gree of nerve damage by drawing the fiber tractography. In Korea, studies on spinal nerve fiber

maps in patients with spinal cord injury have been actively carried out.

| Source | Diffuse tensor imaging and fiber tractography of patients with cervical spinal cord injury. Journal of Neurotrauma 2010;27:2033-2040


The spinal cord is an organ that acts like a phone line connecting the brain and limbs. The spinal

cord delivers motion signals from the brain to the upper and lower limbs and also transmits senso-

ry signals in the opposite direction from the upper and lower limbs to the brain. When an accident

or disease occurs in the spinal cord, the spinal cord completely or incompletely loses its function,

which is called spinal cord injury. Spinal cord injuries are caused by trauma such as car accidents,

falling from a height, and sports injuries, and non-traumatic injuries such as myelitis, tumors, vas-

cular malformations, and spinal stenosis.

Spinal cord injury, like stroke, is a central nervous system injury, but changes in the function

of the patient after the injury are different from those of stroke, which usually appear in the form

of hemiplegia. Because the spinal cord is a collection of various nerve pathways connecting the

brain and limbs in a narrow cylindrical space, the damage will most likely result in loss of function

of both limbs. If a spinal cord injury occurs, the patient may experience a complete or incomplete

loss of movement and sensory nerve function below the injury site, as well as neurogenic blad-

der and neurogenic bowel from autonomic nervous system injury and changes in cardiovascular

control capacity.


Diagnosis of spinal cord injury is made through various methods such as radiological exami-

nations, neurophysiological tests, and neurological examinations. The radiological examination is

performed to confirm the vertebral fracture, dislocation, ossification of posterior longitudinal liga-

ment, spinal stenosis, spinal nerve and nerve root compression, and simple X-ray, Computerized

Tomography (CT) and Magnetic Resonance Imaging (MRI) are also used.

Spinal Cord Rehabilitation

24 25


(3) Overview of the Treatment Method

Spinal cord rehabilitation is aimed at helping patients with tetraplegia or paraplegia who live

with paralysis caused by spinal cord injury to return to the society. It includes functional training

such as movement training that patients with spinal cord injuries can carry out by themselves in

consideration to the degree of paralysis of the spinal cord, production and education of necessary

orthotics, proper wheelchair prescription and training, and educational process of helping patients

and guardians to understand physiological changes such as neurogenic bladder, neurogenic in-

testine, and changes in cardiovascular control ability and teaching them how to manage such

conditions.

Functional training includes movements such as lying down, sitting up, sitting down without

help, and movin from a bed to a wheelchair according to the patient’s level of paralysis. If a patient

with incomplete paralysis has enough the lower limb strength to stand up or walk using a walking

aid device, the training is carried out according to the patient’s condition.

Even if a tetraplegic patient does not have any strength in his or her hands, the patient may be

able to eat, write, and use a computer by oneself if he or she uses an appropriate aid device. For

those who can push the wheelchair by themselves, a wheelchair that suits the patient’s paralysis

condition needs to be prescribed for the training, and the patient needs to be taught how to use

it. For those who cannot push the wheelchair by themselves, an electric wheelchair needs to be

prescribed for the training, and the patient needs to be taught how to use it.

Patients with spinal cord injuries report of having neuropathic pain such as numbness, burning

sensation and sharp pain in the paralyzed area. Several drug treatments have been attempted

but are often found to be not fully effective. Recently, there have been reports that repetitive

transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) have

been shown to be effective in controlling neuropathic pain, and clinical applications and studies

are actively carried out by Korean research teams.

(4) Research Accomplishments Made in Korea

In Korea, a variety of researches on stem cell therapy, rehabilitation therapy, and prognosis

have been conducted by a number of researchers who treat patients with spinal cord injury. The

The neurological examination evaluates in reference to International Standards for Neurolog-

ical Classification of Spinal Cord Injury (ISNCSCI), which have been jointly reorganized by the

International Spinal Cord Society (ISCoS) and the American Spinal Injury Association (ASIA). This

is a globally standardized neurological test used to assess patients with spinal cord injury that

assesses the motor and sensory nerves of patients with spinal cord injury according to a defined

evaluation method and determine the patient’s neurological level and ASIA impairment scale.

AIS is divided into A to E, and AIS A refers to complete injury, while AIS B to D refer to incom-

plete injury, and AIS E indicates a case in which patients who belonged to AIS A to D have been

fully recovered. ISNCSCI is an evaluation method that requires expertise in evaluation. In Korea,

the Korea Spinal Cord Society (KoSCoS) holds ISNCSCI lectures and workshops twice a year and

continues to train domestic medical staffs to improve the accuracy of ISNCSCI evaluation.

ISNCSCI WorksheetFigure 22

| Source | American Spinal Cord Injury Association, www.asia-spinalinjury.org

26 27


improved to AIS D. Subsequent studies are currently being conducted to confirm the efficacy and

stability of neural stem / progenitor cells derived from human fetal brain.

3 Effects of Walkbot Gait Training on Kinematics, Kinetics, and Clinical Gait Function in Para-

plegia. NeuroRehabilitation 2018;42:481-489

In this study, Walkbot, a walking robot developed in Korea, was applied to nine patients with lower

limb paralysis caused by spinal cord injury or tetraplegia caused by brain injury for 43 times for 8

weeks of duration, and the effect of the treatment was confirmed.

4 Improved Gait Speed after Robot-Assisted Gait Training in Patient with Motor Incomplete

Spinal Cord Injury: A Preliminary Study. Ann Rehabil Med 2017;41:34-41

In this study, a total of 29 AIS C and D patients underwent robot-assisted gait training (RAGT) for

30 minutes per day, 5 days a week for 4 weeks, and the results of 10 m walk test (10MWT), Lower

extremity motor score (LEMS), Functional ambulatory category (FAC), Walking index for spinal cord

injury II (WISCI-II) and Berg balance scale (BBS) were obtained for comparison before and after

the treatment. This is a preliminary study that confirms the effect of robot-assisted gait currently

introduced in spinal cord rehabilitation, and follow-up studies are underway.

5 Effects of a 6-Week Indoor Hand-Bike Exercise Program on Health and Fitness Levels in

People With Spinal Cord Injury: A Randomized Controlled Trial Study. Arch Phys Med Reha-

bil 2015;96:2033-2040

In this study, eight patients with spinal cord injuries were treated three times a week for 60 min-

utes with indoor hand bicycles for six weeks, and body mass index (BMI), waist circumference,

body fat percentage, insulin level, and homeostasis model assessment of insulin resistance (HO-

MA-IR) were compared with those of seven control subjects who did not exercise for evaluation.

The results showed that BMI, insulin level and HOMA-IR were significantly lower in the exercise

group, and cardiopulmonary endurance and upper limb strength were also higher compared to the

control group, confirming the effect of continual exercise on patients with spinal cord injury.

6 Transcranial Direct Current Stimulation to Lessen Neuropathic Pain after Spinal Cord Injury:

A Mechanistic PET study. Neurorehabil Neural Repair 2014;28:250-259

This study performed tDCS on eight patients with traumatic spinal cord injury who complained

statistics of the number of papers on spinal injuries that Korean rehabilitation medicine physicians

published in the international journals for the last 10 years are as follows. The number of papers in

the field of neurorehabilitation increased by about 10 times from 3 in 2008 to 26 in 2017.

The Number of Papers on Spinal Injuries that Korean Rehabilitation Medicine

Physicians Published in the International Journals

Figure 23

30

20

25

15

10

5

0

3

73

1316

18

23

26

17

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

17


1 Cardiovascular Monitoring During Video Urodynamic Studies in Persons With Spinal Cord

Injury. Am J Phys Med Rehabil 2018;97:1-6

This study performed continuous cardiovascular monitoring on 34 patients with spinal cord injury

during video urodynamic studies to determine the cardiovascular changes that occurred during a

urodynamic study. This study revealed that autonomic dysreflexia-induced hypertension is one of the

dangerous emergencies that may occur in patients with spinal cord injuries and confirmed through

monitoring that abnormal reflexes may occur during the urodynamic study, which is an important test

for assessing the neurogenic bladder status of patients with spinal cord injuries, providing important

information for the evaluation of patients.

2 Clinical Trial of Human Fetal Brain-Derived Neural Stem / Progenitor Cell Transplantation in

Patients with Traumatic Cervical Spinal Cord Injury. Neural Plast 2015;2015: 630932

This is a study on the effects of transplantation of human fetal brain-derived neural stem / progenitor

cells in 17 AIS A patients with traumatic cervical cord injury and two AIS B patients with traumat-

ic cervical cord injury two of the 17 AIS A patients improved to AIS C, while two AIS B patients

28 29


Walking RobotFigure 24

Walkbot_SⓇ

| Source | walkbot2015.cafe24.com

Morning WalkⓇ

| Source | www.curexo.com

Wearable Walking Robot (WalkON Suit and ANGELEGS)Figure 25

lower limb paralysis patient in 2016 Cybathlon, which is a global robot competition for the disabled

and paralysis patients. Since then, the research teams have been continually working on the de-

velopment, aiming for commercialization.

of neurogenic pain and stomach stimulation on eight control subjects and performed took the

18F-FDG-PET imaging which detects glucose metabolism in the brain, to evaluate cerebral glucose

metabolism. This study confirms that tDCS can normalize excessive focus on pain and control

emotional and cognitive factors of pain. This study is significant in that it confirmed the mechanism

of tDCS, which is emerging as a non-drug therapy for patients with spinal cord injury who report

neurogenic pain even after drug administration.


In Korea, at least one spinal cord rehabilitation specialist is working for rehabilitation therapy of

spinal cord injury patients at each university hospital or general hospital. There are also centers

for spinal cord injury patients at regional rehabilitation hospitals in each region. Walking robots

have recently been used for rehabilitation therapy of patients with spinal cord injuries. In Korea,

domestically developed WalkbotⓇ of P&S Mechanics and Morning WalkⓇ of Curexo have been

used in a number of medical institutions and have been reported to be effective in patients with

spinal cord injury.

The final goal of rehabilitation therapy for patients with spinal cord injury is to “help them recov-

er their health and return to society.” In order to achieve these goals, the therapy provides coun-

seling on home renovation, training for adaptation to life at home, training on driving, physical

education for the disabled, and counseling on the aid devices that can be used at home.

In the case of aid devices, wrist braces, c-shaped spoons, and keyboard typing aids can be

prescribed for patients with limb paralysis by a number of hospitals that treat patients with spinal

cord injuries.

| Source | Angel Robotics, angel-robotics.com | Source | Angel Robotics, angel-robotics.com

Wearable walking robots are developed by Korean researchers, and WalkonⓇ, developed jointly

by Sogang University Robotic system control laboratory and Yonsei University College of Medi-

cine biomechanics and robotic rehabilitation laboratory, won the 3rd place by participating with a

Aid Devices for Patients with Upper Limb ParalysisFigure 26

C-shaped Spoon Keyboard Typing Aid

| Source | For happier life with spinal disorder (Koonja, 2017)

30 31


According to a recently published paper the incidence rate of cerebral palsy in Korea has de-

creased in the past five years despite of the increased incidence rate of high-risk deliveries such

as low birth weight and prematurity (Figure 27). This is an example that shows the high quality

medical care in Korea, including the pediatric rehabilitation medicine.


Diagnosis of cerebral palsy requires detailed medical history with neurodevelopmental exami-

nation, evaluation on abnormal movement pattern and postural abnormality, musculoskeletal ab-

normality, abnormal reflex and postural response. In addition, a comprehensive diagnosis shall be

made by using MRI, brain ultrasound, evoked potentials, EEG, and blood tests that can provide

supplementary information. Diagnosis of cerebral palsy is usually made between one and two

years of age. However, early rehabilitation based on early diagnosis is very important, and special-

ists with an expertise in the neurodevelopmental evaluation can diagnose cerebral palsy in infants

even before the age of six months. Therefore, it is highly recommended for infants suspected of

having cerebral palsy to see pediatric rehabilitation medicine specialists as early as possible.


Unlike rehabilitation therapy in adults, the focus of pediatric rehabilitation in children with cer-

ebral palsy is on learning skills that they have never learned before. Rehabilitation treatment of

children with cerebral palsy focuses on motor development and exercise in terms of a neurode-

velopmental perspective and provides appropriate therapeutic stimuli and experiences during the

critical developmental period through early treatment. The accumulation of such stimuli and expe-

riences induces brain development while reducing the negative factors in brain development to

ultimately lead to functional improvement.

Rehabilitation treatment of cerebral palsy includes physiotherapy such as Vojta or Bobath ther-

apy, occupational therapy for training of daily life activities and cognition, speech therapy for lan-

guage development, medication and injection of Botulinum toxin for spasticity which interferes

with muscles stretching and joints movements, prescription for assistive devices and braces, or-

Incidence Rate of Cerebral Palsy, Prematurity, and Low Birth WeightFigure 27

CP: Cerebral palsy, LBW: Low birth weight

Inci

denc

e (%

)

3.0

2.5

2.0

1.5

1.0

0.5

0.02007 2008 2009 2010 2011

CP

Prematurity

LBW


In children, various disorders, congenital anomalies, and traumatic injuries occur. Of all, cerebral

palsy is one of the most common diseases that are subject to rehabilitation treatment.

Cerebral palsy is a collection of symptoms that indicate abnormalities of movement and pos-

ture due to damage to the immature brain during the maturation process of the brain, especially

within one to two years after birth. As a result, activities are restricted, and sensory, cognitive,

communication, perception, and behavioral impairments as well as convulsion appear as com-

mon symptoms. Spastic cerebral palsy is the most common type of cerebral palsy characterized

by excessive reflexive contraction and shortening of the muscles due to brain damage. Spasticity

is one of the major causes of impaired motor development and postural abnormalities in children.

Brain maturation is completed around the age of four or six years old, and there are many

changes in neurological function in this process. Therefore, early diagnosis and evaluation of cer-

ebral palsy and treatment of spasticity, which is one of the factors that inhibit growth and devel-

opment, are very important.

Pediatric Rehabilitation3

| Source | Yonsei Med J 2018 Aug;59(6): 781-786, SW Kim et al.

32 33


Distribution of the Subjects according to the Type of Cerebral PalsyFigure 28

reduces spasticity by cutting some of the tiny nerve rootlets carrying information from the leg

muscles before the rootlets enter the spinal cord. In children with spasticity, this reduces the

number of abnormal signals that are sent from the leg muscles to the spinal cord. As a result,

there is less tightness in the lower extremities. Orthopedic surgery is considered as a musculo-

skeletal surgery that corrects the deformity or contracture of the joints and shortened muscles

caused by long-term spasticity or abnormal movement pattern. In addition, active rehabilitation

therapy is regarded as a prerequisite for both orthopedic and neurosurgical procedures because

the prognosis is closely related to the rehabilitation treatment after the surgery.

(4) Research Achievements Made in Korea

The statistics of the number of papers on pediatric rehabilitation published by Korean rehabil-

itation medicine doctors in recent 10 years are as follows. The number of papers in the field of

pediatric rehabilitation increased by about eight times from 4 in 2008 to 31 in 2017.

| Source | Korean Database of Cerebral Palsy, 2017 Ann Rehabil Med

Spastic Type

675 subjects

(87.32%)

Choreoathetoid

0 subjects (0%)

Bilateral

505 subjects (74.80%)

Unclassified

1 subject (2.5%)

Unilateral

164 subjects (24.30%)

Ataxic Type

14 subjects

(1.81%)

Unclassified

6 subjects (0.90%)

Unclassified

44 subjects

(5.70%)

Dyskinetic Type

40 subjects

(5.17%)

Dystonic

39 subjects (97.50%)Cerebral Palsy

Total 773 subjects (100%)

thopedic surgery, education on learning disabilities, and vocational rehabilitation for maintenance

of independent living.

Spastic cerebral palsy, which is the most common type in children with cerebral palsy with stiff

muscles, accounts for more than 80 to 90 percent of the pediatric cerebral palsy. In children with

cerebral palsy, it is possible to improve motor development and function by reducing spasticity,

and appropriate treatment of spasticity.

The treatment of spasticity can be largely divided into a medication, injection, and surgical op-

eration. Taking the medication spreads the effect of the medicine throughout the whole body, so

it is often used for children with generalized severe spasticity. Injection therapy largely includes a

nerve blockade by alcohol or phenol and injection of botulinum toxin into the muscle.

In nerve blockade, alcohol or phenol is injected to the nerve. This prevents target muscles from

contracting excessively, thereby reducing spasticity. Botulinum toxin, on the other hand, acts at

the point where the muscle and nerve that send signals to move the muscle meet and reduce

spasticity by decreasing excessive muscle contractions. In addition, since there is a limit to the

maximum dose that can be injected as one dose the injection method of combining botulinum

toxin injection and nerve blockade is preferably used to treat muscles at one time.

Surgical methods include neurosurgery and orthopedic surgery. Neurosurgery is a method that


30

35

20

25

15

10

5

034

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

5

4

3

911 12

20

29

2522

31

812

16

2118

15

23

Cerebral Palsy

Pediatric Rehabilitation

1 Incidence of Cerebral Palsy in Korea and the Effect of Socioeconomic Status: A popula-

tion-based nationwide study. Kim S.W., Jeon H.R., Shin J.C., Youk T., Kim J. Yonsei Medical

Journal 2018;59:781-786

The number of children with cerebral palsy has declined in spite of the increasing prevalence of

34 35



The Korean Society for Pediatric Rehabilitation and Developmental Medicine conducts a review

course for pediatric rehabilitation specialists every year. It also provides opportunities for physi-

cians who practice pediatric rehabilitation to learn basic knowledge of pediatric rehabilitation as

well as the latest research results every year. From 2017, it has been conducting a certification

evaluation test for pediatric rehabilitation specialists in an effort to train specialists in the field of

pediatric rehabilitation. In addition, various advanced rehabilitation treatments using leading edge

technologies are applied to pediatric rehabilitation.

A. Robot-Assisted Gait Therapy (Figure 29)

Using the advanced robot technology, this therapy moves the patient’s paralyzed legs in a re-

peated motion in a normal gait posture to restore damaged nerve and muscle functions.

B. Upper Limb Rehabilitation Therapy using Wearable Sensors (Figure 30)

This is a rehabilitation treatment system that maximizes the therapeutic effect by helping

children to stay motivated by using the high-tech wearable sensor technology and computer

games.

prematurity and low birth weight in Korea for the recent five years. This paper shows that the num-

ber of children with cerebral palsy is decreasing regardless of the economic level of the country,

reflecting the high level of medical system and social welfare policy in Korea.

2 Efficacy and Safety of Letibotulinum Toxin A for the Treatment of Dynamic Equinus Foot

Deformity in Children with Cerebral Palsy: A Randomized Controlled Trial. Hyun Jung

Chang, Bo Young Hong, Sang-Jee Lee, Soyoung Lee, Joo Hyun Park, Jeong-Yi Kwon. Toxins

2017;9:252

The drugs used in the injection therapy for spasticity in children with cerebral palsy are produced in

various countries around the world, and a variety of medicines are currently used in different coun-

tries. This paper describes the results of the injection therapy performed in children with cerebral

palsy by various institutions, using the spasticity medication developed in Korea. The paper showed

that the domestically developed drug was equivalently safe and effective compared to the botox

medication, which is the most commonly used drug in the world.

3 Comparison of Botulinum Toxin Type A Injection and Soft-Tissue Surgery to Treat Hip Sub-

luxation in Children With Cerebral Palsy. Eun Joo Yang, Dong-wook Rha, Hyun Woo Kim,

Eun Sook Park. APMR 2008;89:2108-2113

This study shows that injection of botulinum toxin for the treatment of spastic cerebral palsy is as

effective as the surgical treatment in preventing the progression of hip dislocation.

4 Accuracy of Manual Needle Placement for Gastrocnemius Muscle in children with Cerebral

Palsy checked against ultrasonography. Eun Joo Yang, Dong-wook Rha, Jun Ki Yoo, Eun

Sook Park APMR 2009;90:741-744

This study shows that ultrasound guidance is very important in improving the accuracy of botuli-

num toxin injection therapy in children.

WalkBotFigure 29 Smart Kids GlovesFigure 30

| Source | Neofect, www.neofect.com| Source | P&S Mechanics

36 37



Cancer rehabilitation is defined as the process of assessing the degree of restriction of an

individual’s activities and participation due to structural damage and restricted physical function

caused by cancer itself or treatment of cancer and improving as well as maintaining the patient’s

physical, psychological, and social conditions at optimal levels.

Cancer patients may suffer from a variety of medical conditions, including muscle weakness,

joint contracture, movement disorders, paralysis and neuropathic pain, mechanical pain and patho-

logical fractures due to bone and spinal metastasis, and functional impairments and symptoms

such as swelling of upper and lower limbs, head and neck and abdomen, cognitive impairment,

dysphagia, and dysphonia. Cancer rehabilitation prevents secondary impairment of body damage

and limitations in activities and participation and helps maintain and improve daily life functions

and skills.

Cancer rehabilitation is similar to rehabilitation therapy and treatment method of other diseases

in that it aims for functional improvement, but it requires an accurate application according to the

timeline of the disease progression in consideration of functional changes caused by the cancer

progression, secondary disability, and prognosis on survival.

Breast cancer and gynecologic cancer are the most common types of cancer for which rehabili-

tation therapy is actively performed. In addition, rehabilitation programs for head and neck cancer,

lung cancer, hematologic malignancy, colorectal cancer, and urological cancer are provided, and

treatment programs on pain and fatigue for cancer patients are also actively carried out.


Treating cancer patients involves an interview with the patient to find out cancer-induced pain,

fatigue, and feelings of weakness, followed by physical examination and functional evaluation

for assessment of nervous and musculoskeletal problems and functional limitations. A thorough

evaluation of symptoms and functions can identify problems that require treatment.

Cancer Rehabilitation4

Botulinum Toxin Injection that Uses an Ultrasound GuidanceFigure 32

| Source | A, B. Severance rehabilitation hospital, C. Extra-and intramuscular nerves distributions of the triceps surae muscle as a basis for muscle resection and botulinum toxin injections. Surgical and radiologic anatomy 2009;31:615-621

In addition, Korea maximizes the effect of botulinum toxin injection therapy as a comprehensive

rehabilitation therapy through a systematic and scientific approach based on a multidisciplinary

approach.

Rapael Smart PegboardFigure 31

| Source | Neofect, www.neofect.com

C. Gamified Digital Rehabilitation Therapy Device that Provides Auditory Feedback

This is a rehabilitation therapy system that uses the game to improve sensory feedback and

motivation for treatment to maximize the effect of functional rehabilitation of the upper limb.

38 39


chemotherapy, cancer patients easily feel fatigue with weakened physical strength, atrophy of

muscles, difficulty in movement, weakened cardiopulmonary and immune function, leading to

a high risk of having complications such as pneumonia and pressure sore. A systematic reha-

bilitation program can help prevent decrease of cardiorespiratory functions, reduce fatigue, and

maintain various physical functions.

A. Rehabilitation Therapy in Breast Cancer Patients

After the breast cancer surgery, patients experience weight gain, fatigue, muscle pain, os-

teoporosis, and decreased physical activity. Particularly, patients often suffer from upper limb

dysfunction, such as reduction of the range of motion of the shoulder joints and upper limb

lymphedema, after the surgery. In addition, the sensory change of the surgical site and weakness

of the muscles cause difficulty in daily life. Rehabilitation treatments are applied according to

these main symptoms.

1 Exercise Program for Reduction of Cancer-Related Fatigue

A program composed of stretching exercise, muscle strengthening exercise, and aerobic exercise

using a bicycle and treadmill can be used to reduce common fatigue symptom in cancer patients.

2 Treatment of Upper Limb Dysfunction after the Breast Cancer Surgery

If there is a decrease in the range of motion of the shoulder joint due to tightness of the Pectoralis

Major muscle or soft tissue fibrosis associated with radiotherapy, the posture should be fixed, and

a program of increasing the range of motion, including relaxation massage, stretching of the scar

tissue and shoulder joint exercise, should be carried out along with a training on self-exercise for

patients.

Upper Limb Exercise in Breast Cancer PatientsFigure 34

Post-operational limitation of the range of motion of the pelvis, the pectoralis muscle tight-

ness, myofascial pain syndrome, and axillary web syndrome in patients with breast cancer are

diagnosed by physical examination. The upper extremity lymphedema of the surgical side can

be diagnosed using arm circumference measurement, volume measurement using Perometer,

body water measurement using bioimpedance instrument, and lymphoscintigraphy, which is a

nuclear medicine evaluation. In patients with gynecologic cancer, the lower limb lymphedema

is diagnosed through the same method as the upper limb lymphedema evaluation. In the case

of patients with progressive cancer, if they report weakness, the abnormality of central nervous

system or peripheral nervous system is checked through radiological examination and electro-

myography, and relevant factors, such as muscle atrophy, degree of cardiopulmonary functional

impairment and accompanied depression, are comprehensively analyzed.


Due to the lack of activity for lying on the bed for long hours, surgery, radiation therapy, and

Example of Exercise Program for Cancer PatientsFigure 33

Group Training

Shoulder Flexibility Exercise

Muscle Exercise (using a ball)

Provision of Video

Muscle Exercise for Lymphedema

Patient

40 41


Lower Limb Lymphedema Rehabilitation TherapyFigure 37

B. Rehabilitation Therapy for Gynecologic Cancer Patients

1 Exercise Program for Reduction of Cancer-Related Fatigue

Many gynecologic cancer patients fail to keep up with the recommended level of exercise due to

postoperative fatigue and lower limb lymphedema, and therefore, exercising within a range that

does not increase edema or impair physical function is important. The exercise program includes

stretching exercises, muscle strengthening exercises, and aerobic exercises using bicycles and

treadmills.

2 Complex decongestive Rehabilitation Therapy for Postoperative Lower Limb Edema

After the gynecologic cancer surgery, secondary lymphedema may occur in the lower limbs be-

low the umbilicus, and the complex decongestive physical therapy of manual lymphatic drainage,

compression bandage, exercise, skin care, and pressure stockings can be performed. The therapy

also includes the prompt education of patients on the preventive method and precautions for

lymphedema after the surgery and provides a system that can promptly make patients receive the

treatment in the event of lymphedema. In addition, the therapy uses training, video, and booklets

to help patients perform self-care at home.

C. Rehabilitation Therapy for Head and Neck Cancer

The rehabilitation therapy for head and neck cancer targets treatment of postoperative dyspha-

gia, weakening of the trapezius and sternocleidomastoid muscle due to injury of the accessory

nerve, restriction of the range of motion of the shoulder joint, and lymphedema in the head and

neck region.

1 Exercise Program for weakened muscle strength due to injury of the spinal accessory nerve

3 Rehabilitation Therapy for Axillary Region Web Syndrome

It provides psychological stability and self-management through training and helps improve symp-

toms through stretching of soft tissue and shoulder joints.

Rehabilitation Therapy for Axillary Web SyndromeFigure 35

Manual Lymphatic Drainage and Compression Bandage Method Figure 36

4 Complex Decongestive Physical Therapy for Upper Limb Lymphedema after surgery

Complex decongestive physical therapy is a treatment that uses manual lymphatic drainage, com-

pression bandage, exercise, skin care, and compression stockings, and depending on the degree

of lymphedema the composition of the treatment can be modified.

Complex decongestive physiotherapy is divided into two major phases. The first phase aims for vol-

umetric reduction, and manual lymphatic drainage, compression bandage and exercise therapy are

performed once a day for two to four weeks. When the reduction of edema reaches a certain level,

patients enter the second phase of the long-term maintenance. During this period, the patients

perform self-care, which includes wearing pressure stockings during the day, wearing compression

bandages at night, exercise therapy, and self-skin care.

<Preparation>Bandage: One (6 cm), one (8 cm), two (10 cm)Cotton bandage: One (10 cm) One Stockinet (gauze)

42 43


received international attention by carrying out innovative researches in various fields of cancer

rehabilitation, including the research in which the mobile environment was used to improve the

rehabilitation outcome of cancer patients. The statistics of the number of papers related to cancer

rehabilitation published in international journals by Korean rehabilitation medicine physicians in

the last 10 years are as follows. The number of papers in the field of neurorehabilitation increased

by more than four times from 8 in 2008 to 33 in 2017.

Number of Papers Published by Korean Researchers in International JournalsFigure 38


50

40

30

20

10

02008 2009 2010 2011 2012 2013 2014 2015 2016 2017

8 9 10 11

19

13

19

42

2933

1 Effects of Exercise Intervention in Breast Cancer Patients: is Mobile Health (mHealth) with

Pedometer more Effective than Conventional Program using Brochure? Uhm KE, Yoo JS,

Chung SH, Lee JD, Lee I, Kim JI, Lee SK, Nam SJ, Park YH, Lee JY, Hwang JH. Breast Can-

cer Res Treat. 2017 Feb;161(3):443-452.

This is a paper that demonstrates that recently-developed mobile fitness devices used by breast

cancer patients yield superior effects of exercise compared to the conventional patient training

using brochures.

2 Effects of a Complex Rehabilitation Program on edema status, physical function, and qual-

ity of life in lower-limb lymphedema after gynecological cancer surgery. Do JH, Choi KH,

Ahn JS, Jeon JY. Gynecol Oncol. 2017 Nov;147(2):450-455.

2 Secondary Lymphedema after head and neck surgery

In order to prevent secondary shoulder pain and functional deterioration due to muscle weakness,

the muscle exercise that maintains the range of motion of the joint and gradually strengthens the

weakened muscles can be performed to minimize the inconvenience experienced by patients.

D. Rehabilitation Therapy of Lung Cancer and Esophageal Cancer

1 Pulmonary Rehabilitation Program for improvement of respiration ability before and after

the surgery

This program uses preoperative and postoperative breathing exercises, muscle strength exercises,

and aerobic exercises to shape patients into an operative physical condition and minimize postop-

erative complications.

E. Multidisciplinary and Integrative Medical Treatment System for Cancer Pain

For the treatment of cancer pain, which is known to be difficult to control, the comprehensive

evaluation through psychological and functional evaluation based on thorough consideration of

cancer progression and direction of treatment by cooperating with specialists in oncology, reha-

bilitation, anesthesiology and psychiatry, and it helps to deduct the best treatment outcome by

selecting the treatment combination including medication, rehabilitation and medical procedure.

F. Multidisciplinary and Integrative Medical Treatment System for Bone Metastasis

In the case of metastasis to the spine or bone of the upper or lower limb, the multidisciplinary

team consisting of specialists in oncology, rehabilitation, orthopedic surgery, neurosurgery, and

radiation oncology performs a comprehensive evaluation on tumor treatment, mechanical stabili-

ty, neurological abnormalities, and functional problems to establish a treatment plan, and subse-

quent rehabilitation treatment will provide the best functional results.


Physicians in Korea have been reporting research on the reality and problems of cancer reha-

bilitation and results that provide the effect of rehabilitation therapy from which the best func-

tional results in various cancer types can be derived. Recently, researches carried out in Korea

44 45



The cancer rehabilitation field in Korea has established an efficient cancer rehabilitation sys-

tem for each cancer type and has constructed a treatment system in consideration of surgery,

chemotherapy, radiation therapy, long-term survival period, and recurrence of the cancer patients.

The Korean medical system provides effective patient education through training, booklet, and

multimedia materials to help patients identify common problems of each time period. It also has

established a critical pathway for treatment of frequently-occurring cancer types and application

of systematic and effective treatment.

In particular, the cancer patient symptom management program, which utilizes the developing

mobile environment and big data in the era of 4th industrial revolution, has been developed and

used. Based on the specificity of each type of cancer, such as breast cancer, colorectal cancer,

and liver cancer, the program is customized, and the environment, where the hospital-based reha-

bilitation treatment can be continued at home, is established the best results. This is an example

of an excellent medical management system developed by advanced IT technology and efficient

medical system of Korea.

The best results are achieved through comprehensive approach of the multidisciplinary inte-

grated medical treatment system. Progressive cancer often involves many complex problems.

In particular, the optimal combination of tumor therapy and rehabilitation is very important for

treatment of pain or paralysis. To this end, the rehabilitation medicine in Korea run the effective

system that manages complex symptoms of various cancer patients by effectively integrating the

core value of rehabilitation medicine, which refers to a comprehensive approach, into the field of

cancer rehabilitation.

The most common complication after the gynecologic cancer surgery is the lower limb lymphede-

ma, which often limits activity due to risk of worsening of edema. This study demonstrated the

effectiveness of the complex rehabilitation program through a randomized controlled trial and sug-

gested the treatment modalities that can improve the quality of life for patients with limitation of

activities.

3 Effects of a Physical Therapy Program combined with manual lymphatic drainage on shoul-

der function, quality of life, lymphedema incidence, and pain in breast cancer patients with

axillary web syndrome following axillary dissection. Cho Y, Do J, Jung S, Kwon O, Jeon JY.

Support Care Cancer. 2016 May;24(5):2047-2057.

Axillary web syndrome is one of the problems that breast cancer patients experience after the

surgery. In this study, the authors demonstrated the efficacy of the treatment that uses manual

massaging to improve the quality of life of patients and prevent the complications.

4 Analysis of Factors related to arm weakness in patients with breast cancer-related

lymphedema. Lee D, Hwang JH, Chu I, Chang HJ, Shim YH, Kim JH. Support Care Cancer.

2015 Aug;23(8):2297-304.

Postoperative upper limb lymphedema is a critical complication that lowers the quality of life of pa-

tients. In this study, authors analyzed the factors related to the weakness of upper limb in patients

and suggested ways to prevent them from leading to functional deterioration.

5 Effect of a Pelvic Floor Muscle Training Program on gynecologic cancer survivors with

pelvic floor dysfunction: a randomized controlled trial. Yang EJ, Lim JY, Rah UW, Kim YB.

Gynecol Oncol. 2012 Jun;125(3):705-11.

Cancer patients who underwent gynecologic cancer surgery experience various inconveniences

due to structural and functional changes in the pelvic floor. Receiving the adequate treatment is not

easy, and many patients suffer from chronic pelvic pain and impaired pelvic function. For improve-

ment of such symptoms, the authors demonstrated the effectiveness of the pelvic floor muscle

training program through a randomized controlled trial.

Cardiac Rehabilitation5


Cardiac rehabilitation is an individualized exercise treatment and risk factor management pro-

gram for improvement of cardio-respiratory function and recovery of the subacute phase that

begins immediately after completing the acute managements (Intensive therapy in ICU, drug

46 47


Subject of Cardiac RehabilitationFigure 39

Patient Type

Myocardial infarction, angina pectoris, coronary balloon dilatation and stent procedure

Patient with coronary artery disease

Patient with stable heart failure, advanced heart failureHeart failure patient

Coronary artery bypass graft surgery, valve surgery, left ventricular assist device (LVAD),

heart transplantation, etc.

Patient who received cardiac surgery

Patient with pacemaker, implantable cardioverter defibril-lator (ICD), or cardiac resynchronization therapy (CRT)

Patient who receivedother cardiac procedure

Patient who receivedprocedure or surgery for peripheral artery disease

through cardiac rehabilitation exercise program. The physiological effects of cardiac rehabilitation

on human body are shown in Figure 40.

therapy, procedure and surgery, heart failure therapy, pacemaker and defibrillator insertion, cardi-

ac transplantation, etc.). This is the final step in the heart disease treatment performed to restore

the physical and psychosocial function of patients, and it is a critical treatment process that must

be applied to all cardiac patients.

Cardiac rehabilitation programs involve a variety of medical personnel (physical therapists, nurs-

es, psychotherapists, occupational therapists, clinical nutritionists, social workers, etc.) depend-

ing on the patient’s condition and risk factors. The subjects of cardiac rehabilitation are shown in

the table below and include most of the heart diseases.

Effects of Regular Exercise Program on Whole Body and Cardiac FunctionFigure 40

Age-related ailments↓ Sarcopenia↑ Vascular health

Function↑ Cardiac output↑ Stroke volume

↓ Type ll diabetes↓ HbA1c↑ insulin sensitivity↓ BMI

Cardioprotection↓ Ischemic injury

↑ Aerobic capacity↑ oxidative. phosphorylation↑ mitochondria biogenesis

Macrovascular CAD↓ Plaque progression↓ Restenosis

↓ Hypertension↓ systolic and diastolic blood pressure↑ autonomic function

Vascular↑ vasoreactivity↑ endothelial function↑ Ca2+ handling↑ Collateralization

↓ Dyslipidemia↓ triglyceridesminor ∆ in HDL/LDL

↓ Inflammation↓ ROS↓ C-reactive protein↓ Inflammatory cytokines

Metabolism↑ ox. phosphorylation↑ mito. biogenesis

Systemic Benefits Cardiac BenefitsExercise Training

| Source | Bruning and Sturek. Prog Cardiovasc Dis. 2015

Cardiac rehabilitation not only provides cardiovascular protection for a variety of mechanisms,

but also improves the management of multiple risk factors for the disease, restoring physical and

psychosocial function to minimize heart disease and help patients to be active. In addition, it helps

patients to maintain a well-controlled, healthy lifestyle, in which cardiovascular risk factors are

properly controlled. As a result, it provides the secondary prevention of heart diseases by reduc-

ing recurrence, rehospitalization and reoperation and minimizes the early mortality.

Cardiac rehabilitation improves the whole body’s ability to exercise and reduces the recurrence

of cardiovascular disease, thereby reducing the mortality. In patients with heart failure, hemody-

namic improvement, peripheral vascular and skeletal muscle function improvement, autonomic

nerve function stabilization, improvement of athletic ability, improvement of quality of life, and re-

duction of psychological stress including anxiety and depression can be achieved significantly by

cardiac rehabilitation exercise program. In addition, survival rate also can be improved significantly

48 49



A. Cardiac Rehabilitation Evaluation Equipment

In order to provide the appropriate exercise regimen for the patient, the cardiopulmonary func-

tion and exercise capacity of the patient should be accurately evaluated. The cardiopulmonary ex-

ercise (CPX) test is used for such purpose, and it consists of exercise stress electrocardiography

and ventilator gas analysis.

CPX EquipmentFigure 41

CPX testFigure 42 CPX EquipmentFigure 43

#From the left: treadmill, gas analyzer, stress electrocardiogra-phy and sphygmomanometer

Sphygmomanometer

Pulse Oximeter

Ventilator Gas Analyzers with System Software

Ergometer

TreadmillBicycle Ergometer

Exercise ECG with System Software

10 electrodes for 12 lead electrocardiogram (ECG)

The CPX test assesses the exercise capacity and risk of developing cardiovascular complica-

tions during exercise and is used to make exercise prescription for patients. In particular, if the

risk of cardiovascular complications during exercise is evaluated to be high, the patient should

exercise in hospital while monitoring the electrocardiogram (ECG) and vital signs. The items test-

ed by CPX are as follows.

Items Monitored during the CPX testFigure 44

Heart RateBlood Pressure

Rate Pressure ProductElectrocardiogram

Oxygen ConsumptionOxygen Saturation

Carbon Dioxide ProductionTidal Volume

Respiratory RateMinute Ventilation

Respiratory Exchange RatioRate of Perceived Exertion

B. Cardiac Rehabilitation Therapy Equipment

Once the exercise prescription is made based on the results of the CPX test, the treatment

begins accordingly. Cardiac rehabilitation is basically performed under electrocardiogram (ECG)

monitoring. In addition, blood pressure and rate of perceived exertion (RPE) are also measured.

An emergency cart including a defibrillator should be prepared for emergency. There are many

ways to set the intensity of exercise, and using the heart rate or rate of perceived exertion (RPE)

is the easiest way.

ECG-monitored exercise trainingFigure 45 Equipment for wireless telemetry ECG monitoring

Figure 46

50 51


Overview of Cardiac Rehabilitation TherapyFigure 47


Cardiac rehabilitation program is largely divided into cardiac rehabilitation assessment, cardiac

rehabilitation therapy, and education for secondary prevention. The cardiac rehabilitation program

includes ten core components of patient assessment, diet, weight management, blood pressure

management, blood lipid management, diabetes management, smoking cessation, psychosocial

management, physical activity counseling, and exercise therapy, and they should be carried out

to reach the target values.

Division Contents

Cardiac Rehabilitation EducationRisk factor management education: smoking, diet, exercise, obesity management, habits, psychology

Cardiac Rehabilitation EvaluationTreadmill test: stress electrocardiogram, cardiovascular response, ventilator gas analysis

Cardiac Rehabilitation TherapyIndividualized exercise training with monitoring of ECG, heart rate, blood pressure, & rate of perceived exertions, etc. regular follow-up, reevaluation and retraining, inducing healthy lifestyle

In particular, exercise therapy is the most important key factor in cardiac rehabilitation. It is di-

vided into inpatient cardiac rehabilitation, outpatient cardiac rehabilitation and community-based

cardiac rehabilitation according to the timing and condition after the onset of acute cardiovascular

disease, and the overview of the clinical care guidelines are shown in Figure 48.

A. Inpatient Cardiac Rehabilitation Program

Cardiac rehabilitation starts at Coronary Care Unit (CCU). Cardiac rehabilitation can be initiated

if the cardiovascular symptoms, electrocardiogram (ECG), and myocardial enzyme levels remain

stable for more than 48 hours after the patient’s admission. Usually, patients with simple myocar-

dial infarction without complications can start low intensity exercise two to three days after the

onset under the supervision of medical staffs.

The patient should try to stay in the sitting posture as much as possible even on the bed be-

cause the lying posture increases myocardial oxygen demand more than the sitting posture. The

Critical Pathway for Cardiac Rehabilitation Exercise TherapyFigure 48

Inpatient cardiac rehabilita-

tion treatment

Cardiac rehabilitation treatment as

outpatient

Delayed treatment

as outpatient because of other complications

Community- based cardiac rehabilitation

Simple myocardial in-farction: Inpatient cardiac rehabilitation treatment

for 1-2 days

Complex myocardial in-farction: Inpatient cardiac rehabilitation treatment

for 7-14 days

Cardiac rehabilitation as outpatient: 8–12 weeks

Extended hospitalized cardiac rehabilitation

treatment for 2 more weeks

Acute medical treatment, coronary artery intervention, or bypass graft surgery

Intensive care unit or coronary care unit

Low risk group patient: Conversion to self-exercises

Cardiac rehabilitation at home or community12 weeks

6 weeks

patient should start with breathing exercise, relaxation exercise, and phasic movement using

small muscles and gradually try doing exercise using large muscles, standing and walking. For

patients who had a cardiac surgery, low intensity exercise is recommended 48-72 hours after the

surgery, but patients who underwent sternotomy should be limited to upper body exercise for

three months after surgery. If patients received a minimally invasive surgery that does not require

a sternal incision, their athletic abilities will recover more quickly.

B. Outpatient Cardiac Rehabilitation Program

The outpatient cardiac rehabilitation should be started within the first to two weeks after dis-

charge, and it should be started within three months of the onset, even if the patient misses this

period for medical or socioeconomic reasons. Prior to a full-scale exercise, medical evaluation and

cardiopulmonary exercise tests should be performed to evaluate the risk of heart attack during

52 53


arrhythmia patients with unstable heart rate or patients who use beta-blockers or had heart trans-

plantation.

If a CPX test is performed using a bicycle ergometer, the watts (or METs) of reached target

heart rate are recorded and used to set the exercise intensity in the range of 40-80% of the re-

corded value. The appropriate number of exercises is three to four times a week, but it can be

adjusted according to the condition of the patient. Particularly, patients in the group with high

risk of heart attack during exercise need real-time supervision of the medical staff for monitoring

of the wireless telemetry ECG, blood pressure, heart rate and rate of perceived exertion (RPE)

during the exercise.

C. Community-based Cardiac Rehabilitation Program

This program applies to patients with stable conditions, in which the risk of cardiovascular com-

plications due to exercise is significantly reduced, starting around three months after the onset of

heart disease, and the program is aimed for lifelong self-management by the patient. Patient may

use aerobic exercise equipment at home or work place. Patient should be able to understand the

concepts of exercise intensity control and self-monitoring, may use school playground, walking

tracks, and trails for the program. Exercising three to four times a week is appropriate for one to

one and a half hours at a time, and exercise should become a part of the patient’s leisure activities

and hobbies.

Power walking, mountain climbing, hiking, cycling, badminton, etc. are suitable as a mainte-

nance exercises, but walking, bowling, and golfing using a cart are not suitable because of low

exercise intensity. Exercises that require the eruption of vigorous activity (such as weight lifting,

push-ups, sit-ups, arm wrestling, pull-ups, parallel bars, Korean wrestling, wrestling, Judo, power

running, marathons and triathlon / pentathlon) should be prohibited, and competitive exercises

should be especially avoided.


1 Regular Exercise Training Reduces Coronary Restenosis after percutaneous coronary

intervention in patients with acute myocardial infarction. International Journal of Cardi-

ology 2013

exercise, and exercise prescription and safety guidelines should be prepared based on this eval-

uation.

Exercise during this period is mainly aerobic exercise using treadmill or bicycle ergometer. Each

exercise consists of 5-10 minutes of warm-up periods, 30-50 minutes of main exercise, and 5-10

minutes of cool-down for a total of one hour. Older patients with weaker exercise abilities should

divide the exercise time into a number of short sessions and take rests between them. Exercise

intensity should be determined based on the results of the CPX test, mainly using the target heart

rate calculation method. In other words, the exercise intensity should be determined by the target

heart rate, but it should start from 40% intensity of the reserved heart rate and gradually increase

to 85% over 6-12 weeks according to the onset of the disease and condition of the patient. If the

CPX test shows angina or an electrocardiogram with an ST wave of 1 mm or more, the target

heart rate should be set to be 10 beats/min lower than the heart rate at that time. The exercise

intensity is sometimes determined by the rate of perceived exertion (RPE), which indicates the

degree of subjective difficulty felt by the patient during the exercise. This is especially useful in

Rate of Perceived Exertion (RPE)Figure 49

PerceivedExertion

7

8

9

10

11

12

13

14

15

16

17

18

19

Very, very light

Very light

Fairly light

Somewhat hard

Hard

Very hard

Very, very hard

54 55



In Korea, systematic cardiac rehabilitation with specialized facilities and equipment has been

started since the late 1990s, and since then, the number of hospitals with cardiac rehabilitation

programs has been increasing steadily so that there are currently about 40 hospitals with cardi-

ac rehabilitation programs nationwide, and the number is still increasing. In a recent study that

compared the five year survival rate between the cardiac rehabilitation group and the control

group without cardiac rehabilitation among the 7,136 patients, who were hospitalized for acute

myocardial infarction at a regional cardiac rehabilitation center in Korea, the cardiac rehabilitation

group showed the mortality rate reduced by 50% compared to the control group.

In addition, the cardiac rehabilitation programs provide the patient-centered cardiac rehabili-

tation program to patients with relatively low risk of heart attack during exercise to ensure safe

and effective exercise in a place appropriate for their condition. The patients with low risk can

use personalized heart rate and electrocardiogram monitoring equipment through smart phone

applications to perform self-monitoring exercises after setting the exercise goal at the hospital or

connect their smart phones with hospital computers to exercise safely at home or work.

Cardiac rehabilitation therapy significantly reduced the stent restenosis rate after one year of stent

implantation in acute myocardial infarction patients, which was statistically associated with im-

proved cardiorespiratory performance and HDL cholesterol level.

2 Effect of High Interval Training in acute myocardial infarction patients with drug-eluting

stent. American Journal of Physical Medicine & Rehabilitation 2015

In patients with acute coronary artery disease with stent implantation, the group that carried out

high intensity interval training with the intensity of 85% to 95% of the reserved heart rate showed

a significant increase in the maximum oxygen uptake compared to the group that carried out a

moderate continuous training with the intensity of 70% to 85% of the reserved heart rate.

3 Impact of Aerobic Exercise Training on endothelial function in acute coronary syndrome.

Annals of Rehabilitation Medicine 2014

The results of CPX and flow mediated diameter test performed on patients with acute coronary

artery disease before and after the cardiac rehabilitation showed that the maximal oxygen con-

sumption and degree of vasodilation were significantly increased in the cardiac rehabilitation group

compared to the control group.

4 Need for Systemic Effects to modify health-related behaviors after acute myocardial infarc-

tion in Korea. Circulation Journal 2018

Analysis of 13,452 acute myocardial infarction patients using the National Health Insurance Service

data showed a significantly higher survival rate and fewer reperfusion procedures in patients who

quitted smoking and continued to do adequate physical activities.

5 Impact of Exercise-Based Cardiac Rehabilitation on long-term clinical outcomes in patients with

left main coronary artery stenosis. European Journal of Preventive Cardiology 2016

Of the 3,120 left main coronary artery stenosis patients, 596 patients (19.6%) underwent cardiac

rehabilitation, and this group showed significantly lower crude mortality and cardiovascular dis-

ease-related mortality than those of the control group.

Pulmonary Rehabilitation6


Pulmonary rehabilitation is a comprehensive and intensive treatment with education, a variety

of techniques and devices to help relieve and control symptoms of respiratory illness and prevent

complications from respiratory failure. Through rehabilitation therapy, the patient’s exercise capac-

ity is increased, and the psychological stability is improved so that the patient can demonstrate his

or her best performance in everyday life.

Pulmonary Rehabilitation includes comprehensive treatment, such as patient education, breathing

retraining, relaxation therapy, airway secretion management, reconditioning exercise, and psychological

and nutritional counseling. Using the appropriate respiratory aids for the patients who need ventilatory

support can improve the quality of life of patients and it is important parts of pulmonary rehabilitation.

56 57


A. Cough Assist Device

For many respiratory diseases and after surgery, airway secretion management is one of the

most important factors in prevention of respiratory complications such as pneumonia. Among the

various airway management methods, cough assist device is the most important one.

Cough assist device sold in Korea include Cough and Suction (CNS-100) (S&S Care, Gyeo-

nggido, Korea), Comfort Cough (Seoil Pacific Corp., Seoul, Korea) and Cough Assist® and E70

(Respironics Inc., Murrysville, PA, US). These cough assist devices are similar to vacuum cleaners

in that they also use the suction power of the machine. The device induces coughing by replacing

the functions of the inspiratory muscles and the expiratory muscles by first applying a positive

pressure to the lungs, and applying momentary negative pressure to generate a powerful aerobic

force that acts like a cough.

How to Use the Cough Assist DevicesFigure 50

By putting a nasal and oronasal mask on the patient, it is possible to manage the secretions

without intubation or tracheostomy tube, and it can be a more effective way for clearing secretions

of patients with a tracheostomy tube or intubation tube than using manual suction by a catheter.

B. Non-Invasive Ventilation Assistance

In neuromuscular patients, the respiratory muscles gradually weaken so the patients’ lives

ultimately can be maintained by the help of ventilator. Patients with upper cervical spinal cord

injury are also often required to use a long-term ventilator for their respiratory muscle paralysis.

There are two ways to assist respiration with a ventilator. One is a method of connecting the

ventilator with tracheostomy tube. (hereinafter invasive method), and the other one is a non-in-

vasive method using a nasal mask or mouthpiece. (Fig 51)

Therefore, application of non-invasive respiratory aids(without tracheostomy tube or intuba-

tion tube), taking into consideration characterization of respiratory pathophysiology, is the main

issues for pulmonary rehabilitation. And this method would be used long term care of ventilatory

support for the patients with neuromuscular disease such as muscular dystrophy and spinal cord

injuries.


The patients who are subject to pulmonary rehabilitation are divided into the group with chronic

obstructive lung disease and the group with respiratory muscle weakness. Chronic obstructive

pulmonary disease is characterized by airflow obstruction caused by chronic bronchitis or emphy-

sema. The respiratory muscle weakness group includes neuromuscular disease and spinal cord

injury and also, the treatment may be useful in the patients who did surgical operation even if

the patient is not diagnosed with a specific disease. Therefore, if the postoperative pulmonary

rehabilitation is appropriately applied, respiratory complications can be reduced.

Neuromuscular disease is a disease that affects the peripheral nervous system, including the

anterior horn cell, nerve roots, nerve plexi, peripheral nerve, neuromuscular junctions and muscles,

due to various causes. Progressive muscular dystrophy, Lou Gehrig’s disease, and spinal muscular

atrophy are the main diseases targeted by pulmonary rehabilitation.

In neuromuscular diseases, respiratory complications are caused by ventilatory failure due to

weakening of respiratory muscles and inability of removing airway secretion. In these patients,

respiratory muscle weakness leads to restrictive pulmonary disease with decreased lung volume

and capacity. This increases the load on the respiratory muscles that are weakened during breath-

ing. An increase in the work of breathing can cause decompensation of the respiratory muscles.

In such cases, supportive ventilation should be provided to avoid respiratory muscle fatigue.


Various treatment techniques and devices are used for pulmonary rehabilitation, but the two

most important techniques are cough assist device and non-invasive ventilation assist device.

58 59


This study analyzed the effectiveness of pulmonary rehabilitation in patients with scoliosis who

have weak respiration, who failed to meet the standard of safe surgical indication (lung capacity of

30%) at the time of surgery. This study received attention by reporting that pulmonary rehabilita-

tion enables more patients to receive surgery safely.

3 Successful Tracheostomy Decannulation after complete or sensory incomplete cervical

spinal cord injury. Spinal Cord. 2017 Jun;55(6):601-605.

This study was conducted to verify that patients with spinal cord injuries with tracheostomy tube,

who needed the ventilator, could use ventilatory with noninvasive method after decannulation and

improve the quality of life by appropriately using the pulmonary rehabilitation.


Although pulmonary rehabilitation is a field that can be effectively used for respiratory system

management in internal medicine patients or prevention of postoperative complications as well

as rehabilitation fields, it is extremely rare to utilize this properly internationally.

Since 2000, Korea has refined its academic and clinical system of pulmonary rehabilitation and

has reached the highest level in the world. As a result, 24 trainees from around the world have

studied pulmonary rehabilitation in Korea from 2010 to 2018, and many doctors are waiting for

the training. Since 2014, Philips, a global medical device company, has recognized Korea’s high

international status and has participated in the international education project. (Fig 52)

Non-invasive methods can be performed with nasal, oral, or oronasal mask. Most patients

prefer non-invasive methods using a nasal mask. However, if the nose is heavily congested or

obstructed by cold symptoms, the non-invasive methods using a mouthpiece or oronasal mask

should be used. In a patient who uses a non-invasive ventilator using a mouthpiece, air leaks

during nighttime sleep can be minimized by using a lipseal.


In Korea, many leading clinical studies on pulmonary rehabilitation have been published. Here

are some of the most recent research results.

1 Clinical Implications of Assisted Peak Cough Flow Measured With an External Glottic Con-

trol Device for Tracheostomy Decannulation in Patients With Neuromuscular Diseases and

Cervical Spinal Cord Injuries: A Pilot Study. Arch Phys Med Rehabil. 2016 Sep;97(9):1509-

1514.

The purpose of this study was to develop a simple and effective device to induce cough and to

report its effectiveness in performing decannulation of tracheostomy state. (J Rehabil Med. 2012

Apr;44(4): 351-4.) In addition to the measurement instruments used in this study, the authors are

also conducting internationally leading research in pulmonary rehabilitation, including developing

instruments that can be used in patients in actual practice. (J Rehabil Med. 2012 Apr;44(4):351-4.

Cough assistance device for patients with glottis dysfunction and/or tracheostomy.)

2 Pulmonary Rehabilitation to decrease perioperative risks of spinal fusion for patients with

neuromuscular scoliosis and low vital capacity. Eur J Phys Rehabil Med. 2016 Feb;52(1):28-35.

Invasive Method and Non-Invasive Ventilation Assist MethodFigure 51

International Pulmonary Rehabilitation Training Partnership CeremonyFigure 52

60 61


adult robots equipped with a pediatric lower limb module can be used.

(2) Evaluation Method and Advanced Equipment

The rehabilitation robot supports the operation of the upper limb or the lower limb through the

built-in program and the electric motors. It is a device that gives feedback about the patient’s reac-

tion measured by the sensor and is different from a continuous passive motion (CPM) developed

for simple join excercise. In particular, advanced forms of rehabilitation robots provide guidance

forces for active auxiliary joint movements through impedance control.

Gait rehabilitation robot therapy can provide accurate and constant repetitive training to pa-

tients, who are unable to move their own paralyzed legs due to disabilities, and help them regain

leg strength and control ability to eventually walk alone.

This allows for task-specific training and more intensive gait training over a longer period of

time with a minimum of one assistant. During training, the sensor can easily monitor the gait to

give feedback, control the degree of support of the mechanical external force according to the

patient’s physiological gait patterns, and appropriately adjust the joints to improve the walking

pattern.

Visual feedback using virtual reality may be used to provide a therapeutic environment and

stimuli similar to the actual situation. These rehabilitation robots have an advantage that they can

not only evaluate the training but also evaluate the force (torque) and motion of the upper and

lower limbs.

In the 2000s, rehabilitation robots for functional recovery from stroke and spinal cord injuries

have been widely used, and various rehabilitation robots have been introduced and developed in

Korea. Major rehabilitation robots approved by the Ministry of Food and Drug Safety as medical

devices are shown in Figure 53.

Robot-Assisted Rehabilitation7

(1) Introduction of Diseases

A. Stroke

Robot-assisted rehabilitation therapy is most actively applied on stroke with many clinical stud-

ies performed. In patients with upper or lower hemiparesis, intensive rehabilitation during the

subacute phase is important, when neurological recovery is predominant. At this time, robot-as-

sisted rehabilitation therapy, which repeatedly induces precise movements, is effective in promot-

ing neural plasticity and restoring normal movement patterns. In addition, there is a possibility that

it may be effective during the chronic phase after the stroke.

B. Traumatic Brain Injury

Although cognitive impairment is often the main symptom, robotic-assisted rehabilitation ther-

apy in subacute phase is beneficial in the case of traumatic brain injury involving the motor path-

way, as in hemorrhagic stroke.

C. Spinal Cord Injury

If bilateral lower limb paralysis is severe, it is difficult to perform gait training with only one phys-

ical therapist. In this case, robot-assisted gait rehabilitation therapy is effective.

D. Parkinson’s Disease

Although the drug based on dopamine (a neurotransmitter) is the main therapy method, gait

training is also important to reduce stiffness and learn normal gait patterns. Effective training can

be carried out through the gait rehabilitation robot, and robot-assisted rehabilitation treatment can

be applied at the time of day, when the drug effect appears. Recently, there have been several

studies on the use of robotic gait training in Parkinson’s disease patients in Korea.

E. Cerebral Palsy

Even when a considerable period of time has elapsed after birth, the gait pattern is often im-

proved when treated with gait rehabilitation. Gait rehabilitation robots developed for children and

62 63



A. Upper Limb Robot-Assisted Rehabilitation Therapy

Using the upper limb rehabilitation robot, the upper limb function of hemiplegia patients caused

by stroke, traumatic brain injuries, or brain tumors can be significantly recovered. In the case of

advanced rehabilitation robots, such as InMotion Robot and ArmeoPower (Figure 53), the robots

provide full power for the patients with little upper limb muscle strength and provide real-time

assistance to patients with intact muscle strength to help them reach (graphic user interface) the

task goal of the graphic user interface.

Patients with some rigidity can also use the therapy, and by setting resistance on the robotic

arm, patients with much muscle strength left can train more effectively. In addition, patients can

Major Upper and Lower Limb Rehabilitation Robots used in KoreaFigure 53

ArmeoPower

Neuro-X

Lokomat

GEO system

ArmeoSpring

ReoGo

Walkbot

Reo Ambulator

InMotion robot

Amadeo

Morning Walk

SUBAR-01

expect improvement in the cognitive function by participating in the training with an interest in

the monitor game screen that is similar to the virtual reality. It may be a game that is not difficult

for normal people, but it can become a customized treatment for people with cognitive and upper

limb dysfunction caused by the brain disease. In addition, the robot apparatus is equipped with a

function of evaluating the upper limb function of the patient and measuring the performance of

the robot treatment.

B. Lower Limb Robot-Assisted Rehabilitation Therapy

Lower limb rehabilitation robot is relatively simpler in categorization than the upper limb rehabil-

itation robot and can be divided into the exoskeleton type and end-effector type. In Korea, Loko-

mat and Walkbot (Figure 53), the exoskeleton-type robots, are usually used in clinical practice, and

the Morning Walk (Figure 53), an end-effector type robot, has also been used by many hospitals.

The benefits of using lower limb rehabilitation robots are that they can provide a repetitive train-

ing in an accurate and constant manner to patients who cannot move their lower limbs to help

them regain the lower limb muscle strength and control ability to walk by themselves.

The rehabilitation robot enables provision of a task-specific training, and it allows an intensive

gait training for a long period of time with a minimum number of assistants (one person). Also, it

can easily monitor the gait conditions during training and give feedback, control the level of guid-

ance force according to the patient’s gait pattern and help the patient to learn how to maintain the

proper joint movements in a pattern similar to a normal gait to improve the gait pattern.

In addition, visual feedback using virtual reality can provide a therapeutic environment and stim-

ulation similar to the actual situation, which can motivate patients and increase their participation

in training. Patients’ satisfaction with lower limb rehabilitation robot therapy is quite high, and

many patients are excited by the fact that they can walk using the robots. In addition, Lokomat

allows a pre-treatment and post-treatment comparison analysis through the evaluation program

built into the robot equipment.

(4) Research Achievements made in Korea

In Korea, various researches have been conducted on the effectiveness of upper and lower limb

rehabilitation robot therapy.

64 65


2 Hwang CH, Seong JW, Son DS. Individual finger synchronized robot-assisted hand rehabil-

itation in subacute to chronic stroke: a prospective randomized clinical trial of efficacy. Clin

Rehabil. 2012 Aug;26(8):696-704.

This study showed that 17 patients with chronic stroke had a more significant improvement in the

hand function, muscle strength, and range of motion when treated with robot-assisted hand reha-

bilitation therapy for four weeks than the group treated for two weeks.

0.4

0.44

0.48

0.52

Smoothness 0.56

Single task DST COWAT

0

0.02

0.04

0.06

0.08Reach Error

Single task DST COWAT

1 Shin JH, Park G, Cho DY. Cognitive-Motor Interference on Upper Extremity Motor Perfor-

mance in a Robot-Assisted Planar Reaching Task Among Patients With Stroke. Arch Phys

Med Rehabil. 2017 Apr;98(4):730-737.

Two-dimensional upper limb rehabilitation robotic therapy performed on 22 chronic stroke patients

improved smoothness of the upper limb movement and reach errors and affected the cogni-

tive-motor interference.

3 Kim SY, Yang L, Park IJ, Kim EJ, JPark MS, You SH, Kim YH, Ko HY, Shin YI. Effects of Inno-

vative WALKBOT Robotic-Assisted Locomotor Training on Balance and Gait Recovery in

Hemiparetic Stroke: A Prospective, Randomized, Experimenter Blinded Case Control Study

With a Four-Week Follow-Up. IEEE Trans Neural Syst Rehabil Eng. 2015 Jul;23(4):636-42.

13 patients with stroke showed improved independent walking ability, balance ability and ability to

carry out daily activities compared to the conventional treatment group when they were treated

with gait therapy using the domestically developed robot named Walkbot for four weeks.

4 Kim J, Kim DY, Chun MH, Kim SW, Jeon HR, Hwang CH, Choi JK, Bae S. Effects of ro-

bot-(Morning Walk®) assisted gait training for patients after stroke: a randomized controlled

trial. Clin Rehabil. 2018 Oct 16:269215518806563.

This study showed that 25 patients with stroke had significant improvement in lower extremity

muscle strength and balance ability compared to the conventional treatment group when they

were treated with Morning Walk robot-assisted gait therapy for three weeks.

66 67


7 Bang DH, Shin WS. Effects of Robot-assisted gait training on spatiotemporal gait parame-

ters and balance in patients with chronic stroke: A randomized controlled pilot trial. Neu-

roRehabilitation. 2016 Apr 6;38(4):343-9.

This study showed that four weeks of robot-assisted gait training on nine chronic stroke patients

improved the walking speed, stride, balance ability, and self-confidence in balance compared to

the treadmill gait training group.

8 Cho DY, Park SW, Lee MJ, Park DS, Kim EJ. Effects of Robot-assisted gait training on the

balance and gait of chronic stroke patients: focus on dependent ambulators. J Phys Ther

Sci. 2015 Oct;27(10):3053-7.

This study proved that four weeks of robot-assisted gait training on 20 chronic stroke patients

significantly improved lateral reaching and independent walking ability, which were not improved

by conventional gait training.


16

14

12

10

8

6

4

2

0RAGT group RAGT group Control Control

VO2peak(mL/min) baPWV(m/s)

Post-trainingPre-training

6 Han EY, Im SH, Kim BR, Seo MJ, Kim MO. Robot-assisted gait training improves brachi-

al-ankle pulse wave velocity and peak aerobic capacity in subacute stroke patients with

totally dependent ambulation: Randomized controlled trial. Medicine (Baltimore). 2016

Oct;95(41):e5078.

This study showed that four weeks of lower limb robot-assisted rehabilitation along with the regu-

lar gait training in 30 subacute stroke patients who were unable to walk improved the arterioscle-

rosis and maximal aerobic capacity compared to the control group.

5 Yang HE, Kyeong S, Lee SH, Lee WJ, Ha SW, Kim SM, Kang H, Lee WM, Kang CS, Kim DH.

Structural and functional improvements due to robot-assisted gait training in the stroke-in-

jured brain. Neurosci Lett. 2017 Jan 10;637:114-119.

This study demonstrated that the 20 sessions of robot-assisted gait training in 10 stroke patients

who cannot walk improved the clinical assessment scale and promoted neuroplasticity in the sup-

plementary motor area (SMA) of the affected brain.

68 69


alone, when they received a combination of robot-assisted gait training and the ankle extensor

functional electrical stimulation for five weeks.

10 Chang WH, Kim MS, Huh JP, Lee PK, Kim YH. Effects of Robot-Assisted Gait Training on

Cardiopulmonary Fitness in Subacute Stroke Patients: a randomized controlled study. Neu-

rorehabil Neural Repair. 2012 May;26(4):318-24.

The results of this study showed that 20 patients in the subacute phase of stroke had a significant

improvement in the lower extremity function and maximal oxygen consumption compared to the

conventional exercise treatment group when the robot-assisted gait therapy was performed five

times a week for two weeks.

9 Bae YH, Ko YJ, Chang WH, Lee JH, Lee KB, Park YJ, Ha HG, Kim YH. Effects of Robot-Assist-

ed Gait Training Combined with Functional Electrical Stimulation on Recovery of Locomotor

Mobility in Chronic Stroke Patients: A Randomized Controlled Trial. J Phys Ther Sci. 2014

Dec;26(12):1949-53.

This study showed that 10 stroke patients in the chronic phase had improvements in the stride

length and the maximum knee angle, which were not improved by the robot-assisted gait training


Based on the results of previous studies, the upper limb rehabilitation robot therapy is effective

in improving the upper limb function, strength, and daily life performance in stroke patients. The

rehabilitation robot therapy has the advantage and therapeutic effect different from the gait thera-

py performed by a physical therapist, and it especially shows a significant therapeutic effect in the

subacute stroke patients within three months of the onset.

In Korea, where traditional manual therapies have been historically developed, rehabilitation

70 71


medicine specialists in cooperation with physical and occupational therapists provide the opti-

mized rehabilitation therapy using various rehabilitation robots. In addition, through active clinical

research, researchers are constantly searching for better robot-assisted rehabilitation therapies.

Using the rehabilitation robot, it is possible to maximize the effect of rehabilitation treatment by

providing a sufficient number of repetition and treatment capacity that cannot be provided by the

conventional manpower and system. The rehabilitation robot plays an important role because

it provides a sufficient amount of rehabilitation training for patients in the sub-acute phase, the

golden time of the stroke recovery, and its role is even more important because there is a lack

of manpower and other therapeutic and institutional methods capable of providing a consistent

upper limb training to patients in the chronic phase.

The Korean Society for Rehabilitation Robot (KORERO) was established on May 31, 2018, with

participation of rehabilitation medicine specialists and robot engineers. It is expected to carry out

activities through a multidisciplinary approach in the future.

Inaugural Meeting of the Korean Society of Rehabilitation Robot (KORERO).Figure 54

Successful Clinical Cases of Rehabilitation Therapy in Korea 3Rehabilitation

(1) A Case of Spinal Cord Rehabilitation in a Spinal Cord-Injured / Paralyzed

Patient

A 25-year-old Vietnamese patient C, who was treated at Korean hospital A, was working at a

Korean tire factory in Vietnam on April 7, 2012, when the shoulder and entire left part of the body

were pulled into the machine. The patient had limb paralysis and was transferred to a local hos-

pital. The patient was diagnosed to require surgery for the ligament injuries and instability of the

cervical spine, C6/7 and T1 injuries of spinal cord, and left clavicle fracture revealed in the radiolog-

ical test. On May 5, 2012, the patient was referred to the department of neurosurgery, received

the operation on May 11, 2012, and was transferred to the rehabilitation medicine department of

hospital A on May 24, 2012.

At that time, the patient was unable to sit by himself due to the incomplete paralysis of all the

muscles except the right shoulder. The patient was confirmed to have peripheral nerve injuries

in the nerve conduction test and needle electromyography, and the medical staff confirmed the

degree of muscle strength improvement every week to determine the stage and extent of the

rehabilitation treatment.

During the rehabilitation therapy period of about three months, the patient was trained to sit by him-

self, stand up using a parallel pole, stand up and walk with a walking aid, and walk with a cane. From

June 25, the patient had received a robot-assisted gait therapy using a walking robot until the patient

was discharged, and through the robot-assisted gait training, the patient was able to experience a

normal walking pattern and improve the walking pattern. The patient recovered to a level that he could

walk alone through the treatment process at hospital A for three months and returned to Vietnam.

Spinal Cord Rehabilitation1

72 73

Successful Clinical Cases of Rehabilitation Therapy in Korea Smart Care - Rehabilitation

Pediatric Rehabilitation2

(1) A Case of Pediatric Rehabilitation in a Cerebral Palsy Patient

A 12-year-old girl from Kazakhstan visited the hospital with tiptoe gait. On the day of the visit,

the child went through a physical examination, a simple imaging test, and brain magnetic reso-

nance imaging and was diagnosed as cerebral palsy.

On the second day, the child was injected with botulinum toxin on both calf muscles and re-

ceived the rehabilitation treatment, including physical therapy and occupational therapy, everyday

for two weeks. Also, the child learned exercises that can be done at home for maintenance of the

treatment effect. After termination of treatment, the child’s tiptoe gait was significantly improved

and has visited Korea every September for regular check-up and treatment at the rehabilitation

medicine department.

This case was very helpful in publicizing Korea as well as its medical system. Since then, many

children with cerebral palsy in Kazakhstan have been referred to the rehabilitation medicine de-

partment in Korea every year.

(2) A Case of Pediatric Rehabilitation in a Limb Paralytic Cerebral Palsy Child

A 10-year-old boy from Russia came to Korea in 2013 and returned home after being diagnosed

with cerebral palsy at a pediatric clinic. One year later, he was referred to the rehabilitation medi-

cine department for muscle rigidity. The child had a limb paralytic cerebral palsy, which is a form of

complex cerebral palsy, and muscle rigidity with motor abnormality was observed.

The child complained of pain in the shoulder and neck muscles and said he suffered from a

difficulty in moving the limb joints because of the recent growth in height. On the day of the visit,

he was seen by a rehabilitation medicine specialist and received radiologial tests.

To alleviate the pain that the child was experiencing, medication was administered. On the

second day of the visit, he was treated with botulinum injections for spasticity and received ankle

joint assist device prescription for spasticity and limb muscle rigidity.

The child was greatly improved in spasticity and returned to Russia after the 10th visit to the

hospital. Since then, he has visited Korea every six months for treatment, and the hospital has

prepared a medical certificate and a prescription in English so that he can receive treatment and

assist device management at a local medical institution in his home country.

(3) A Case of Pediatric Rehabilitation in a Spastic Cerebral Palsy Patient

A six-year-old boy from Abu Dhabi was born as a premature baby and was diagnosed with spas-

tic cerebral palsy in his home country. Althoug he received treatment, he could not sit or stand up

alone. He was referred to Korea for rehabilitation treatment, and spasticity of the adductors at the

hip joint was found to be the main cause of the functional impairments. Botulinum toxin injection

therapy was performed.

After injection, he received an intensive comprehensive rehabilitation treatment, including hy-

drotherapy and robot-assisted gait therapy, and his lower limb functions improved to a level,

where he was able to do a gait training using a walker. He visits Korea every six months to receive

botulinum toxin injection and intensive rehabilitation treatment, and customized orthosis is being

manufactured.

74 75


Cancer Rehabilitation3

(1) A Case of a Breast Cancer Patient with Lymphedema

A 63-year-old woman was diagnosed with breast cancer and underwent a mastectomy. After

the surgery, she felt swelling in her right arm and used a high-elastic compression bandage, but

the pain and swelling became worse. She visited the rehabilitation medicine lymphedema clinic.

After the treatment, she received lymphedema education and complex lymphedema physical

therapy, and the symptoms were significantly improved.

However, after the intensive treatment, the maintenance therapy and self-care treatment were

Improved Right-hand Lymphedema through RehabilitationFigure 55

not properly carried out, which led to worsening of edema again, and fibrosis caused pain. She

visited the rehabilitation medicine department and received a treatment using a compression

bandage as well as other compression materials for deteriorated lymphedema and fibrosis, and

the symptoms were improved again.

After the treatment, the patient’s quality of life was improved, and the continual management

and maintenance have been done well so far.

(2) A Case of Gynecologic Cancer Patient with Lymphedema

A 43-year-old woman was diagnosed with gynecologic cancer and underwent laparoscopic

radical hysterectomy and bilateral pelvic lymphadenectomy. Postoperative chemotherapy and ra-

diotherapy were performed. After one month of treatment, edema was observed from the thigh

to the toes of the right lower limb.

At first, the symptoms were left for observation because they were not severe, but during the

following three months, she felt the right leg was heavier with sore pain. She visited the reha-

bilitation medicine and lymphedema clinic, and was diagnosed with right lower limb edema and

prescribed for the complex lymphedema physical therapy, during which she received a patient ed-

ucation, lymphatic drainage and compressive bandage. After one month of intensive treatment,

the lower extremity edema was greatly improved, and the patient was able to carry out daily life

activities, such as walking.

Compression Therapy ProcessFigure 56

76 77


Cardiac Rehabilitation4

(1) A Case of a Cardiac Rehabilitation Patient with Advanced Heart Failure

A 50-year-old male patient received drug treatment for heart failure caused by dilated cardiomy-

opathy since 1996. In December 2011, he came to the emergency department after losing con-

sciousness, and atrial fibrillation was observed. CPR was performed for 40 minutes. He under-

went hypothermia therapy, ventilator therapy through tracheostomy and regained consciousness

after three months. In April 2012, he was transferred to the rehabilitation medicine department

and started the cardiac rehabilitation treatment program. At the beginning of the program, his

maximum oxygen uptake was measured to be 13.5mL/kg/min and received 50-minute cardiac

rehabilitation session five times a week for eight weeks. After the treatment, his maximum ox-

ygen uptake was improved to 19.4mL/kg/min. After he was discharged, he visited the hospital

three times a week for the cardiac rehabilitation therapy, and the maximum oxygen uptake was

measured to be 19.5mL/kg/min in the cardiopulmonary exercise test performed in December

2012. The left ventricular ejection fraction improved from 14% before the cardiac rehabilitation to

19% in September 2012, and he recovered to a level, at which he could carry out daily activities.

Affected Lower Limb before (left) and after (right) the TreatmentFigure 57 Hemodynamic Results of Symptomatic Limitation Exercise TestFigure 58

Apr 26, 2012 Jun 13, 2012 Dec 26, 2012

METs (Metabolic Equivalents) 3.9 5.5 5.6

Maximal Heart Rate 167 178 151

Rate Pressure Product 21,710 19,936 15,015

VO2max 13.5 19.4 19.5

Symptomatic Limitation Exercise Test and Electrocardiogram Monitoring during exercise

Figure 59

Patients with chronic heart failure easily complain of dyspnea and fatigue during exercise, re-

sulting in decreased activities in home and society. Such conditions make patients gain psycho-

logical and psychological disabilities, such as psychological atrophy and depression. The primary

cause of these problems is a decrease in cardiac output, but the resulting secondary functional

depression of the peripheral blood vessels, skeletal muscles, respiratory system worsens the

overall symptoms. Therefore, cardiac rehabilitation can be a very important alternative to heart

failure therapy, when there can be no effective treatment to improve cardiac output.

78 79


(1) A Case of Pulmonary Rehabilitation in a Spinal Muscular Atrophy Patient

Patient Oh was diagnosed with spinal muscular atrophy of unknown etiology shortly after birth.

This is an incurable disease, where muscles of the body gradually atrophied and are lost as the pa-

tient grows up. During the first year of high school, he suffered from dyspnea while having a meal

and finally a cardiac arrest occurred. After then, he was transferred to the intensive care unit. At

that time, he was unable to breathe, so he had an emergency tracheostomy operation and lived a

life depending on the ventilator, although at that age it would have been natural to hang out with

friends. The patient visited many hospitals to improve the respiratory function but did not find any

treatment that was more advanced than the one he already had.

However, he found hope in the pulmonary rehabilitation. Although he could not detach the

ventilator due to respiratory difficulty through the pulmonary rehabilitation therapy, he succeeded

in removing the tracheostomy. This enabled him to go back and finish school, and he went to a

college to achieve his dream.

(2) A Case of Pulmonary Rehabilitation in a Patient with Limb Paralysis

Patient Kim was in a car accident and injured his cervical spine, resulting in a severe generalized

paralysis in his whole body. In addition, for repeated pneumonia and respiratory insufficiency,

he received a tracheostomy operation and became to live on a ventilator all the time. As a fairy

tale writer, it was a great agony to live 24 hours a day with whole body paralysis and mechanical

ventilation.

Because pulmonary rehabilitation therapy was not a familiar field for doctors, it had some prob-

lems at first, but once the pulmonary rehabilitation therapy began, the patient started seeing

hope. Through various pulmonary rehabilitation exercises, the tracheotomy tube could be re-

moved successfully. Through this, he was able to speak again, and the time he was on the venti-

lator gradually diminished. He successfully returned to the society and has given lectures to the

youth on children’s literature as his job.

Pulmonary Rehabilitation5(3) A Case of Pulmonary Rehabilitation in a Patient with Pompe’s Disease

Pompe’s disease is a rare hereditary metabolic disorder caused by the accumulation of the gly-

cogen. The patient was diagnosed with Pompe ‘s disease at around 3 years of age and has been

visiting the hospital every 2 weeks to date for injection therapy. He had a respiratory failure but

was unaware of it until he was 11 years old, when he had a sudden exacerbation of respiratory

insufficiency and got a ventilator installed through an endotracheal tube. As the respiratory failure

continued, the doctors decided to perform a tracheostomy operation. His parents, who did not

want to perform an incision on their child’s neck, and desperately looked for an alternative therapy,

heard of the pulmonary rehabilitation therapy and transferred their son to the specialized pulmo-

nary rehabilitation hospital.

Fortunately, through the pulmonary rehabilitation, the tube was removed, and the respiratory

insufficiency was successfully treated without an invasive ventilation. After he was discharged, he

still has severely paralyzed limbs and uses mechanical ventilator via nasal mask at night, but like

his peers, he goes to school and dreams of going to college.

80 81


Domestic Medical Processfor Foreign Patients4Rehabilitation

One-Stop Medical Services for Foreign Patients1

Post-departure

4DuringStay

3

OnArrival

2

Pre-arrival

1

Fast Track Immigration & Airport Pick-up

•�Fast Track Immigration service are available at Incheon airport.•�Ambulance accompanied by medical

staff and accommodation transfer is provided with request.

Customized Services for Patients and Families

•�Medical ServicesMedical related services are providedby each designated hospitals such as escort to medical appointments and examinations, interpretation (Arabic, English, Korean, ect.)

•�Non Medical ServicesCenter for Middle East provides Non-medicalServices such as visa extension, 24/7 medical call, help desk, monitoring and reporting for patients and family.

Post-care Services

•��U-Healthcare System allows medical care staying cooperated with patients’ doctor in their home countries.•��Temedicine centers to strengthen

post-care services.

Real-time Online System & Concierge Services

•�One-click Medical Portal Website for medical information.•�medicalpackage.visitmedicalkorea.com

Rehabilitation-Specialized Medical Institutions in Korea5Rehabilitation *The medical institutions are sorted in alphabetical order.

1 Asan Medical Center

88, Olympic-ro 43-gil, Songpa-gu, Seoul eng.amc.seoul.kr

2 Bobath Memorial Hospital

155-7, Daewangpangyo-ro, Bundang-gu, Seong-nam-si, Gyeonggi-do

www.bobath.co.kr

3 Bong Seng Memorial Hospital

401, Jungang-daero, Dong-gu, Busan www.bongseng.co.kr

4 Bundang Jesaeng Hospital

20, Seohyeon-ro 180beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do

www.dmc.or.kr

5 Busan Adventist Hospital

170, Daeti-ro, Seo-gu, Busan www.symcb.co.kr

6 Catholic Kwandong University International St. Mary’s Hospital

291, Simgok-dong, Seo-gu, Incheon www.ish.or.kr

7 CHA Bundang Medical Center

59, Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do

bundang.chamc.co.kr

8 CHA Gangnam Medical Center

566, Nonhyeon-ro, Gangnam-gu, Seoul gangnam.chamc.co.kr

9 CHA Gumi Medical Center

12, Sinsi-ro 10-gil, Gumi-si, Gyeongsangbuk-do kumi.chamc.co.kr

10 Chaum Hospital, Chungdam

442, Dosan-daero, Gangnam-gu, Seoul www.chaum.net

11 Cheju Halla General Hospital

65, Doryeong-ro, Jeju (Yeon-dong) www.hallahosp.co.kr

12 Cheongju Medical Center

48, Heungdeok-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do

www.cjmc.or.kr

13 Cheongshim International Medicine Center

267-177, Misari-ro, Seorak-myeon, Gapyeong-gun, Gyeonggi-do

www.csmc.or.kr

14 Chonbuk National Univeristy Hospital

20, Geonji-ro, Deokjin-gu, Jeonju-si, Jeollabuk-do

www.cuh.co.kr

82 83

Rehabilitation-Specialized Medical Institutions in Korea Smart Care - Rehabilitation

15 Chonnam National University Hospital

42, Jebong-ro, Dong-gu, Gwangju www.cnuh.com

16 Chosun University Hospital

365, Pilmun-daero, Dong-gu, Gwangju hosp.chosun.ac.kr

17 Chung-Ang University Hospital

102, Heukseok-ro, Dongjak-gu, Seoul ch.cauhs.or.kr

18 Chungbuk National University Hospital

776, 1sunhwan-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do

www.cbnuh.or.kr 19 Chungnam National Univeristy Hospital

282, Munhwa-ro, Jung-gu, Daejeon www.cnuh.co.kr

20 Daegu Catholic University Medical Center

33, Duryugongwon-ro 17-gil, Nam-gu, Daegu www.dcmc.co.kr

21 Daegu Fatima Hospital

99, Ayang-ro, Dong-gu, Daegu www.fatima.or.kr

22 Daegu Medical Center

157, Pyeongri-ro, Seo-gu, Daegu www.daegumc.co.kr

23 Daejeon Sun Hospital

29, Mokjung-ro, Jung-gu, Daejeon www.sunhospital.com

24 Daerim St. Mary’s Hospital

657, Siheung-daero, Yeongdeungpo-gu, Seoul www.drh.co.kr

25 Dankook University Hospital

201, Manghyang-ro, Dongnam-gu, Cheonan-si, Chungcheongnam-do

www.dkuh.co.kr

26 Dong Rae Bong Seng Hospital

27, Anyeon-ro 109beon-gil, Dongnae-gu, Busan www.bongseng.com

27 Dong-A University Hospital

26, Daesingongwon-ro, Seo-gu, Busan www.damc.or.kr

28 Dongguk University Hospital

87, Dongdae-ro, Gyeongju-si, Gyeongsangbuk-do www.dumc.or.kr

29 Dongguk University Ilsan Oriental Hospital

27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do

www.dumc.or.kr

30 Ewha Womans University Medical Center

1071, Anyangcheon-ro, Yangcheon-gu, Seoul www.eumc.ac.kr

31 Gachon University Gil Medical Center

21, Namdong-daero 774beon-gil, Namdong-gu, Incheon

foreigner.gilhospital.com

32 Gangnam Severance Hospital

211, Eonju-ro, Gangnam-gu, Seoul gs.iseverance.com

33 GangNeung Asan Hospital

38, Bangdong-gil, Sacheon-myeon, Gangneung-si, Gangwon-do

www.gnah.co.kr

34 Godoil Hospital

505, Gangnam-daero, Seocho-gu, Seoul www.godoil.com

35 Gunsan Medical Center

29-1, Jigok-dong, Gunsan-si, Jeollabuk-do www.kunmed.or.kr

36 Guro Sungsim Hospital

427, Gyeongin-ro, Guro-gu, Seoul www.kurosungsim.co.kr

37 Gwangmyeong Sungae Hospital

36, Digital-ro, Gwangmyeong-si, Gyeonggi-do h.ksungae.co.kr

38 Hallym University Chuncheon Sacred Heart Hospital

153, Gyo-dong, Chuncheon-si, Gangwon-do chuncheon.hallym.or.kr

39 Hallym University Dongtan

Sacred Heart Hospital

7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do dongtan.hallym.or.kr

40 Hallym University Kangdong

Sacred Heart Hospital

150, Seongan-ro, Gangdong-gu, Seoul www.kdh.or.kr

41 Hallym University Medical Center

12, Beodeunaru-ro 7-gil, Yeongdeungpo-gu, Seoul

hangang.hallym.or.kr

42 Hyemin General Hospital

85, Jayang-ro, Gwangjin-gu, Seoul www.e-hyemin.co.kr

43 Incheon Baek Hospital

214, Saetgol-ro, Dong-gu, Incheon www.baek-hospital.com

44 INHA International Medical Center

84, Gonghang-ro 424 beon-gil, Jung-gu, Incheon www.inhaim.com

45 Inha University Hospital

27, Inhang-ro, Jung-gu, Incheon www.inha.com

46 Inje University Busan Paik Hospital

75, Bokji-ro, Busanjin-gu, Busan www.paik.ac.kr/busan

47 Inje University Haeundae Paik Hospital

875, Haeun-daero, Haeundae-gu, Busan www.paik.ac.kr/haeundae

48 Inje University Ilsan Paik Hospital

170, Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do www.paik.ac.kr/ilsan

49 Inje University Sanggye Paik Hospital

1342 Dongil-ro, Nowon-gu, Seoul, Korea www.paik.ac.kr/sanggye

50 Jeju National University Hospital

(Arai 1-dong) 15, Aran 13-gil, Jeju www.jejunuh.co.kr

51 Kangbuk Samsung Hospital

29, Saemunan-ro, Jongno-gu, Seoul www.kbsmc.co.kr

52 Keimyung University Dongsan Medical Center

56, Dalseong-ro, Jung-gu, Daegu www.dsmc.or.kr

84 85

Rehabilitation-Specialized Medical Institutions in Korea Smart Care - Rehabilitation

53 Konkuk University Medical Center

120-1, Neungdong-ro, Gwangjin-gu, Seoul www.kuh.ac.kr

54 Konyang University Hospital

158, Gwanjeodong-ro, Seo-gu, Daejeon www.kyuh.ac.kr

55 Korea University Anam hospital

73, Inchon-ro, Seongbuk-gu, Seoul anam.kumc.or.kr

56 Korea University Ansan hospital

123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do (Gojan-dong)

ansan.kumc.or.kr

57 Korea University Guro Hospital

148, Gurodong-ro, Guro-gu, Seoul guro.kumc.or.kr

58 Kosin University Gospel Hospital

262, Gamcheon-ro, Seo-gu, Busan (Amnam-dong) www.kosinmed.or.kr

59 Kyung Hee University Medical Center

23, Kyungheedae-ro, Dongdaemun-gu, Seoul www.khmc.or.kr

60 Kyung Hee University Hospital at Gangdong

892, Dongnam-ro, Gangdong-gu, Seoul www.kuims.or.kr

61 Kyungpook National University Hospital

130, Dongdeok-ro, Jung-gu, Daegu www.knuh.kr

62 Kyungpook National University Medical Center

807, Hoguk-ro, Buk-gu, Daegu (Hakjeong-dong) www.knuch.kr

63 Myongji Hospital

55, Hwasu-ro 14beon-gil, Deogyang-gu, Goyang-si, Gyeonggi-do

www.mjh.or.kr

64 Nasaret International Hospital

98, Meonugeum-ro, Yeonsu-gu, Incheon www.nasaret.co.kr

65 National Medical Center

18-79, Euljiro 6-ga, Jung-gu, Seoul www.nmc.or.kr

66 NHIS Ilsan Hospital

100, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do www.nhimc.or.kr

67 Pusan National University Hospital

179, Gudeok-ro, Seo-gu, Busan www.pnuh.or.kr

68 Pusan National University Yangsan Hospital

20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do

www.pnuyh.co.kr

69 Rehabilitation Nursing Sarang Hospital

9, Bongsannam 3-gil, Yeosu-si, Jeollanam-do saranghosp.com

70 Samsung Changwon Hospital

50, Hapseong-dong, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do

smc.skku.edu:442

71 Samsung Medical Center

81, Irwon-ro, Gangnam-gu, Seoul www.samsunghospital.com

72 Samyook Medical Center

82, Mangu-ro, Dongdaemun-gu, Seoul www.symcs.co.kr

73 Seoguipo Medical Center

(Donghong-dong) 47, Jangsu-ro, Seogwipo-si, Jeju-do

www.jjsmc.or.kr

74 Seoul National University Boramae Medical Center

20, Boramae-ro 5-gil, Dongjak-gu, Seoul www.brmh.org

75 Seoul National University Bundang Hospital

82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do

www.snubh.org

76 Seoul St. Mary’s Hospital of the CatholicUniversity of Korea

505, Banpo-dong, Seocho-gu, Seoul www.cmcseoul.or.kr

77 Severance Hospital

50-1, Yonsei-ro, Seodaemun-gu, Seoul sev.iseverance.com

78 Soonchunhyang University Hospital, Cheonan

31, Suncheonhyang 6-gil, Dongnam-gu, Cheonan-si, Chungcheongnam-do

www.schmc.ac.kr/cheonan

79 Soonchunhyang University Hospital, Seoul

59, Daesagwan-ro, Yongsan-gu, Seoul www.schmc.ac.kr

80 Soonchunhyang University Hospital, Bucheon

170, Jomaru-ro, Bucheon-si, Gyeonggi-do www.schmc.ac.kr

81 Sungae Hospital

22, Yeouidaebang-ro 53-gil, Yeongdeungpo-gu, Seoul www.sungae.co.kr

82 The Catholic University of Korea, Bucheon St. Mary’s Hospital

327, Sosa-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do www.cmcbucheon.or.kr

83 The Catholic University of Korea,Incheon St. Mary’s Hospital

56, Dongsu-ro, Bupyeong-gu, Incheon www.cmcism.or.kr

84 The Catholic University of Korea, St. Vincent’s Hospital

93, Jungbu-daero, Paldal-gu, Suwon-si, Gyeonggi-do

www.cmcvincent.or.kr

85 The Catholic University of Korea, Uijeongbu St. Mary’s Hospital

271, Cheonbo-ro, Uijeongbu-si, Gyeonggi-do www.cmcujb.or.kr

86 The Catholic University of Korea,Yeouido St. Mary’s Hospital

10, 63-ro, Yeongdeungpo-gu, Seoul www.cmcsungmo.or.kr

87 Wonju Severance Christian Hospital

20, Ilsan-ro, Wonju-si, Gangwon-do www.ywmc.or.kr

88 Wonkwang University Oriental Medical Hospital Iksan

895, Muwang-ro, Iksan-si, Jeollabuk-do www.wkuh.org

+82-1577-7129

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