Bioimpedance Analysis for Predicting Outcomes of Complex Decongestive Therapy for Gynecological Cancer Related Lymphedema: A Feasibility Study

Objective@#To determine whether the bioimpedance analysis (BIA) ratios of upper to lower extremities could predict treatment outcomes after complex decongestive therapy (CDT) for gynecological cancer related lymphedema (GCRL). @*Methods@#A retrospective study, from March 2015 to December 2018, was conducted. The study sample comprised patients receiving CDT, 30 minutes per day, for 10 days. Bioimpedance was measured pre- and post-CDT. Circumference measurements were obtained at 20 and 10 cm above the knee (AK) and 10 cm below the knee (BK). We calculated the expected impedance at 0 Hz (R0) of extremities and upper/lower extremity R0 ratios (R0U/L). We evaluated the relationship between R0U/L and changes in R0U/L and circumferences, pre- and post-CDT. @*Results@#Overall, 59 patients were included in this study. Thirty-one lower extremities in 26 patients comprised the acute group, and 38 lower extremities in 33 patients comprised the chronic group. Pre-treatment R0U/L was significantly correlated with R0U/L change after adjusting for age and BMI (acute: R=0.513, p<0.01; chronic: R=0.423, p<0.01). In the acute group, pre-treatment R0U/L showed a tendency to be correlated with circumference change (AK 20 cm: R=0.427, p=0.02; AK 10 cm: R=0.399, p=0.03). @*Conclusion@#Our study results suggested that pre-treatment BIA could predict volume reductions after CDT in the early stages of GCRL. These findings implied that BIA value could be one possible parameter to apply in treatment outcomes prediction, during the early stage of GCRL. Therefore, further large-scale prospective studies will be beneficial.

Current Practice and Barriers in Cancer Rehabilitation: Perspectives of Korean Physiatrists / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to assess clinical practice and barriers associated with cancer rehabilitation from the perspective of Korean physiatrists. MATERIALS AND METHODS: All active members of the Korean Academy of Rehabilitation Medicine were invited to complete an online survey developed after focus group discussions. RESULTS: A total of 97 physiatrists (72 males and 25 females) in Korea completed the survey. Of these, 77% reported familiarity with the term 'cancer survivors.' More than 50% of respondents reported that they provided rehabilitation services for patients with breast cancer (61.9%), brain tumors (64.9%), and spinal tumors (63.9%), whereas 86.6% of respondents reported that they had never or rarely provided rehabilitation programs for patients with gynecological, colorectal, or prostate cancer. Physiatrists who received referrals from a well-organized cooperative referral system reported providing services such as exercise programs for patients with gynecological cancer (odds ratio [OR], 2.16; p=0.044) as well as education regarding lymphedema (OR, 1.81; p=0.047) and neuropathic pain (OR, 1.96; p=0.026). CONCLUSION: Although most of the physiatrists surveyed believed that they should contribute to the management of cancer patients, they considered themselves ill equipped to provide appropriate rehabilitation services. This lack of understanding of the effectiveness of rehabilitation services for cancer patients and absence of a cooperative referral system are the major barriers to providing rehabilitation services to cancer survivors in Korea.

Cancer Rehabilitation: Experience, Symptoms, and Needs

The aim of this study was to examine the experience of cancer patients undergoing rehabilitation, to identify symptoms associated with rehabilitation from cancer, and to assess the need for rehabilitation services for cancer patients. Cancer patients (n = 402) at the Asan Medical Center (Seoul, Korea) were enrolled from June to September 2008. A chart review was used to collect demographic and clinical data, including type of cancer, current treatment, time from initial diagnosis to screening, and cancer stage. Each participant provided informed consent and was then given a questionnaire that asked about experience with rehabilitation, symptoms associated with rehabilitation, and the need for different types of rehabilitation services. Clinicians recommended rehabilitation for 8.5% of patients, and 6.7% underwent rehabilitation. Among study patients, 83.8% had one or more symptoms associated with rehabilitation, and 71.6% of patients with symptoms wanted rehabilitation management. The need for rehabilitation was associated with the presence of metastasis, advanced cancer stage, time to diagnosis, and type of current treatment. Our results provide specific information about particular functional symptoms and the rehabilitative needs of subgroups of cancer patients. It is suggested to develope and implement rehabilitation programs for cancer patients.

The Effect of Treadmill Exercise on Ischemic Neuronal Injury in the Stroke Animal Model: Potentiation of Cerebral Vascular Integrity

PURPOSE: This study was done to identify whether pre-conditioning exercise has neuroprotective effects against cerebral ischemia, through enhance brain microvascular integrity. METHODS: Adult male Sprague-Dawley rats were randomly divided into four groups: 1) Normal (n=10); 2) Exercise (n=10); 3) Middle cerebral artery occlusion (MCAo), n=10); 4) Exercise+MCAo (n=10). Both exercise groups ran on a treadmill at a speed of 15 m/min, 30 min/day for 4 weeks, then, MCAo was performed for 90 min. Brain infarction was measured by Nissl staining. Examination of the remaining neuronal cell after MCAo, and microvascular protein expression on the motor cortex, showed the expression of Neuronal Nuclei (NeuN), Vascular endothelial growth factor (VEGF) & laminin. RESULTS: After 48 hr of MCAo, the infarct volume was significantly reduced in the Ex+MCAo group (15.6+/-2.7%) compared to the MCAo group (44.9+/-3.8%) (p<.05), and many neuronal cells were detected in the Ex+MCAo group (70.8+/-3.9%) compared to the MCAo group (43.4+/-5.1%) (p<.05). The immunoreactivity of laminin, as a marker of microvessels and Vascular endothelial growth factor (VEGF) were intensively increased in the Ex+MCAo group compared to the MCAo group. CONCLUSION: These findings suggest that the neuroprotective effects of exercise pre-conditioning reduce ischemic brain injury through strengthening the microvascular integrity after cerebral ischemia.

Prediction of Treatment Outcome with Bioimpedance Measurements in Breast Cancer Related Lymphedema Patients

OBJECTIVE: To investigate the usefulness of bioimpedance measurement for predicting the treatment outcome in breast cancer related lymphedema (BCRL) patients. METHOD: Unilateral BCRL patients who received complex decongestive therapy (CDT) for 2 weeks (5 days per week) were enrolled in this study. We measured the ratio of extracellular fluid (ECF) volume by using bioelectrical impedance spectroscopy (BIS), and single frequency bioimpedance analysis (SFBIA) at a 5 kHz frequency before treatment. Arm circumferences were measured at 10 cm above and below the elbow before and after treatment. We also investigated whether there is correlation between ECF ratio and SFBIA ratio with the change of arm circumference after CDT. RESULTS: A total of 73 patients were enrolled in this study. The higher ECF ratio was significantly correlated with higher reduction of arm circumference at both above and below the elbow after treatment, but the higher SFBIA ratio was correlated only with the higher reduction of arm circumference below the elbow. CONCLUSION: These results show that ECF volume measurements and SFBIA before treatment are useful tools for predicting the outcome of patients with lymphedema. We concluded that ECF volume measure can be used as a screening tool for predicting treatment outcome of BCRL patients.

Effects of Erythropoietin in Hypoxia-Induced Ischemia on Differentiated Human Neuroblastoma SH-SY5Y and Rat Stroke Model / 대한정신약물학회지

OBJECTIVE: The hematopoietic cytokine, erythropoietin (EPO) is known to have neuroprotective effects including promotion of neuronal survival and regeneration after ischemic injury. This study was to investigate the effects of EPO on synaptogenesis and neural restoration in the ischemic condition on neuronal differentiated SH-SY5Y cells and on the behaviors in rat animal model induced by middle cerebral artery occlusion. METHODS: We analyzed the neurite outgrowth and the gene expression of differentiated human neuroblastoma SH-SY5Y cells after the hypoxic stress. Moreover, we performed the motor functional behavior test in EPO treatment of Sprague Dawley rats following cerebral ischemia induced by middle cerebral artery's occlusion (MCAO). RESULTS: Treatment of 2 and 10 units EPO for 1 week showed increase of neurite outgrowth SH-SY5Y cells, compared with non-treatment group (p < 0.05). The results of reverse transcriptase-polymerose chain reaction (RT-PCR) also showed that both synaptophysin (SYP) genes and Growth Associated protein 43 (GAP43) genes in EPO treated cells were significant increased compared with non-treated ischemic group, respectively. The foot fault behavior was recovered in MCAO with EPO treatment group than MCAO group, significantly. CONCLUSION: The elongation of neurite and the increased expressions of SYP and GAP43, and recovered behavioral evidence in the EPO treatment are involved in possible role in neural restoration and synaptogenesis in hypoxic injuried brain. In this study, we suggest that EPO treatment will be may supportive medication to stroke patients to improve the functional brain disturbance.

Stroke in Colorectal Cancer Patients

OBJECTIVE: To find the characteristics of stroke in colorectal cancer patients. METHOD: We retrospectively analyzed 32 patients of stroke in colorectal cancer who were operated from January 2001 to December 2002 by reviewing their charts and brain CTs or MRIs. The type, risk factor, localization and origin of stroke and the stage of colorectal cancer were analyzed. RESULTS: The mean age was 69.2 years. TNM stage II (41%) was the most common. Twenty-three cases were ischemic stroke, four were hemorrhagic stroke and the others were unidentified. Diabetes (63%), hypertension (53%), cardiac disease (19%), and family history of stroke (9%) were observed in patients. The main cause of ischemic stroke was arterial thrombosis, and lacunar and middle cerebral infarction were more common in ischemic stroke. CONCLUSION: Several common risk factors between colorectal cancer and stroke were observed, and these risk factors are associated with the atherosclerosis of cerebral vascular system. To reduce the incidence of cerebrovascular disease and colorectal cancer, we may need to control those risk factors.

Gullain-barre Syndrome Associated with Non-Hodgkin's Lymphoma

A 67-year-old man developed swelling of the right leg with inguinal and abdominal pain over a period of 5 days. Excisional biopsy of the left supraclavicular lymph nodes revealed the diffuse, large B cell type of malignant lymphoma. After chemotherapy, he complained of a tingling sensation and weakness in the left upper extremity, and then this progressed to quadriplegia. Electrodiagnostic testing demonstrated the characteristic findings of demyelination, which was consistent with Guillain-Barre syndrome (GBS). Non-Hodgkin's Lymphoma (NHL) leading to GBS, as was observed in the present case, suggests that physicians should be aware of GBS and non-Hodgkin's lymphoma as the full spectrum of these diseaseshas not been fully defined.

The Two Year's Follow Up Study of Symptomatic Hands without Electrodiagnostic Evidence of Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to determine the natural history of symptomatic hands without electrodiagnostic evidence of carpal tunnel syndrome (CTS). METHOD: This study was comprised of 88 hands of 49 subjects with symptoms consistent with CTS without median mononeuropathy who were recruited during a community health examination and followed after two years. 88 hands of 44 people with age and sex-matched healthy controls were followed for comparison. Symptoms and electrodiagnostic findings were compared between the two groups. RESULTS: 62 hands of the symptomatic group had persistent symptoms after 2 years while 16 hands of the control group had symptoms consistent with CTS. Median motor distal latencies were significantly delayed after two years in the symptomatic group (p<0.05). Median sensory latencies were also delayed in the symptomatic group, but this was not statistically significant (p=0.064). The occurrence rate of median mononeuropathy at wrist was significantly higher in the symptomatic group than in the control group (13.6% vs. 2.3%)(p<0.05). CONCLUSION: The results of this study suggested that a significant number of symptomatic hands without electrodiagnostic evidence of CTS may have persistent symptoms and may progress to electrodiagnostically evident CTS.

The Comparative Analysis between Digital Infrared Thermography Imaging and Three-phase Bone Scintigraphy in the Post-hemiplegic Complex Regional Pain Syndrome

OBJECTIVE: To evaluate the benefit of digital infrared thermography imaging (DITI) and three-phase bone scintigraphy (TPBS) for detecting the post-hemiplegic complex regional pain syndrome (CRPS). METHOD: DITI and TPBS were done in 26 patients with post-hemiplegic CRPS clinically and 14 hemiplegic patients without CRPS as controls. Positive findings were interpreted when the affected hands were 1.0degrees C higher than those of unaffected hands in DITI system and pathological uptake in the regions of interest (hands without fingers-carpal bones, metacarpal bones and metacarpopharyngeal joints) in delayed phase of the TPBS. RESULTS: The sensitivities of DITI and TPBS to detect CRPS were the same to each other as 46.2%, and specificities were 85.7% and 100% respectively. Nineteen of 26 patients (sensitivity=73.1%) were interpreted as abnormal when at least one test showed a positive finding. As a result, an increased diagnostic strength was achieved. CONCLUSION: These findings suggest that the combination of TPBS and DITI can improve the diagnostic strength of post- hemiplegic CRPS.

Follow Up of Asymptomatic Hands in the Patients with Unilateral Carpal Tunnel Syndrome

OBJECTIVE: To know whether nerve conduction study (NCS) could predict later development of carpal tunnel syndrome (CTS) in asymptomatic hands of the patients with unilateral CTS. METHOD: Thirty four patients with unilateral CTS were studied. Subjects were divided into groups with or without the delay of latency, based on the results of initial NCS of asymptomatic hands. After follow up for more than 6 months clinically and electrodiagnostically, the development of CTS in initially asymptomatic hands was compared between groups. RESULTS: At follow up, CTS was diagnosed in 83% of the subjects in the group with motor latency delay at first study, while it was diagnosed in 32% of the subjects in the group without motor latency delay. In the group with sensory latency delay at first study, CTS was diagnosed in 78% of subjects at follow up, whereas only 19% of the subjects developed CTS in the group without sensory latency delay. The incidence of CTS at follow up was significantly higher in the group with motor or sensory latency delay at first study. CONCLUSION: In unilateral CTS, latency delay in motor or sensory NCS of asymptomatic hands may suggest a greater risk of later development of CTS.

Prevalence and Risk Factors of Ulnar Neuropathy at the Elbow in a Rural Population

OBJECTIVE: The purpose of this study was to investigate the prevalence and risk factors of ulnar neuropathy at the elbow (UNE) in a rural district in Korea. METHOD: Among the 578 residents in a rural district who participated in the health examination, 450 (116 male, 334 female) adults were randomly selected. A symptom questionnaire and electrodiagnostic studies were used to diagnose UNE. General characteristics, female-related factors, work-related factors and anthropometric measurements were compared between normal and UNE group to identify the risk factors of UNE. RESULTS: Subjects with UNE were 29 (6.4%), symptom without electrodiagnosis findings 23 (5.1%), asymptomatic subjects were 379 (84.2%). Diabetes mellitus, repetitive heavy lifting were risk factors of UNE. CONCLUSION: The prevalence of UNE was 6.4% in a rural district and these data suggest that medical conditions like diabetes mellitus and physical factors like repetitive heavy lifting are risk factors of UNE.

Prevalence and Risk Factors of the Foot Pain in University Freshmen: One Year Follow-up Study

OBJECTIVE: The purpose of this study was to investigate the prevalence and risk factors of the foot pain in university freshmen and one year follow-up study. METHOD: The subjects were interviewed about the prevalence and risk factors of the foot pain, which were followed up one year later. RESULTS: In a total of 1, 784 subjects, the prevalence of the foot pain was 22.3% with 17.4% in men and 27.6% in women. The foot pain in the groups was significantly associated with gender, the height of heels, the size of shoes, the recent change of shoes, trauma, change in weight, the shoe type at present and the daily walking distance. There was no significant relation between foot pain and the other parameters, such as body mass index, change of the shoe type or change in height. One hundred and fifty seven subjects were reevaluated after one year. The prevalence of the foot pain was 30.6% with 25.4% in males and 34.9% in females. CONCLUSION: The prevalence of the foot pain was 22.3% in university freshmen and 30.6% in one year follow up study, and was significantly associated with shoe problems and lifestyles.

The Optimal Electrical Stimulation Frequency to Improve the Muscle Endurance in Spinal Cord Injured Rabbit

OBJECTIVE: Clinical application of Functional Electrical Stimulation (FES) was limited due to the muscle fatigue phenomenon. This study was undertaken to find an electrical stimulation frequency, which optimally improves muscle endurance in spinal cord injured rabbit. METHOD: Fifteen rabbits were experimentally spinal cord injured at the T10 or T11 spinal cord level. Three kinds of stimulation frequency (10, 20, 40 Hz) and sham control stimulation were applied to the tibialis anterior muscle of each four group for 1 hour per day, for 2 weeks. Muscle fatigue index and peak torque were measured during electrical stimulation, and proportion of the type I musclefiber was measured at ATPase (pH 9.4) staining. RESULTS: Complete paraplegia was obtained in all 12 rabbits. Muscle fatigue index and peak torque were not changed after 2 weeks of electrical stimulation in all four groups. The proportion of the type I muscle fiber was reduced in all four groups after 2 weeks. However, 40 Hz stimulation group showed less decline in proportion of type I muscle fiber than control or 10 Hz group. CONCLUSION: High frequency electrical stimulation applied at an early stage of spinal cord injury is more effective in preserving muscle endurance than low frequency stimulation.

The Correlation of Electrodiagnostic Severity, Severity of Symptom, Functional Status, and Clinical Severity in Patients with Carpal Tunnel Syndrome

OBJECTIVE: To evaluate the correlation of electrodiagnostic severity, severity of symptom, and clinical severity in carpal tunnel syndrome (CTS). METHOD: The sixty eight patients with documented CTS in outpatient clinic from January, 2000 to June, 2001 were included (9 male, 59 female, averaged age 50.0+/-8.8 years). We evaluated the severity of symptom, functional status of ADL with the Levine' questionnaire, and clinical severity with 3 kinds of examination (thenar atrophy, sensory change, and Phalen's test). The electrodiagnostic severity was classified according to Stevens' classification and compared with the severity of symptom, functional status, and clinical severity. RESULTS: The electrodiagnostic severity was classified into three degrees. Five patients (7.4%) were classified into mild degree, 32 patients (47.1%) moderate degree, 31 patients (45.6%) severe degree. The average of severity of symptom scores were 28.4+/-8.5, 31.8+/-7.4, and 31.8+/-9.1 respectively, and there was no significant difference (p>0.05) between the groups. Functional status scales were 14.2+/-6.7, 15.6+/-5.4 and 18.9+/-7.0 respectively and no significant difference (p=0.07) but there was a tendency that the severer was electrodiagnostic severity, the more decreased functional status scale. The clinical severity showed a significant correlation with the electrodiagnostic severity (p<0.05). CONCLUSION: The electrodiagnostic severity has a significant correlation with the clinical severity, but not with the severity of symptom, the functional status in CTS.

Plantar Nerve Injuries Related to Calcaneal Fractures

OBJECTIVE: We investigated plantar nerve injuries associated with calcaneal fracture and severity of disability. METHOD: From July, 2001 to June, 2002, twelve patients who had calcaneal fractures with persistent foot pain and paresthesia were included in our study. We examined electromyography for medial and lateral plantar nerve, inferior calcaneal nerve, also evaluated types of calcaneal fracture and severity of pain and disability with nerve injury. RESULTS: The intraarticular types were 13 cases, extraarticular type was 1 case and communited types were 2 cases. In the electromyographic findings, the 9 cases were diagnosed asneuropathy. In a cases with neuropathy, 8 persons complained over moderate degree of pain and all persons complained over moderate degree of walking disability. However one of three persons without neuropathy complained over moderate degree of walking disability. So disability tended to be more severe in cases with neuropathy. CONCLUSION: We think that neuropathy associated with calcaneal fracture is a cause of aggravation of pain and walking disability, and electromyography for nerves of foot will be needed in the calcaneal fracture.

Digital Image Motion Analysis of the Pharyngeal Movement during Swallowing in Dysphagia Patients

OBJECTIVE: To reveal basic mechanism regarding the swallowing difficulty in stroke and inflammatory myopathy patients, and to compare this with normal persons. METHOD: Five volunteers without any swallowing problems, three inflammatory myopathy patients and five stroke patients with swallowing difficulty and a similar movement of the hyoid bone were included in this study. Videofluoroscopic swallowing studies were performed in all subjects, and their videofluoroscopic motions were analyzed through 2-dimensional motion analysis using the APAS (Ariel Performance Analysis System). RESULTS: The motions of the hyoid bone and the epiglottis of the inflammatory myopathy patients were much smaller than those of the volunteers but their pattern was similar to the volunteers. Although the difference in the displacement of the hyoid bone and epiglottis between the stroke patients and volunteers was low, the movement pattern between them was different. During an excursion of the hyoid bone, there was an interruption in its motion, which may be due to the spasticity of the cricopharyngeal muscle. CONCLUSION: In inflammatory myopathy patients, the cause of the dysphagia is a weakness of the swallow-related muscles but in stroke patients, spasticity of the upper esophageal constrictor muscle, i.e. the cricopharyngeal muscle, may be another cause. Relieving the spasticity of the cricopharyngeal muscle as well as strengthening of the swallow-related muscles should be considered when treating stroke patients with dysphagia.

Prevalence and Risk Factors of Carpal Tunnel Syndrome in Diabetic Patients

OBJECTIVE: To investigate the prevalence and risk factors of carpal tunnel syndrome in diabetic patients. METHOD: Electrodiagnostic study was performed to diagnose carpal tunnel syndrome and polyneuropathy in 266 (male 151, female 115) diabetic patients. General charateristics, diabetes related factors, anthropometric factors were compared between non-carpal tunnel syndrome and carpal tunnel syndrome groups to identify the risk factors for carpal tunnel syndrome. RESULTS: Prevalence of carpal tunnel syndrome in diabetic patients was 16.2 % (43 subjects). Female, farming, wrist depth width ratio (>or=0.7) were associated with carpal tunnel syndrome in diabetic patients. In right hand, odds ratio was 12.82 (95% confidence interval: 2.97~55.3) in female, 5.15 (95% confidence interval: 1.17~22.7) in farming, 28.53 (95% confidence interval: 1.80~451.1) in wrist depth width ratio (>or=0.7). The similar results were also observed in left hand. CONCLUSION: The results suggest that occupation, sex, and anthropometric factor like wrist shape were more associated with carpal tunnel syndrome in diabetic patients than diabetes mellitus itself.

Clinical and Electrophysiologic Features in Four Cases of Castleman's Disease with Peripheral Polyneuropathy

Castleman's disease is a rare clinicopathological entity characterized by multicentric angiofollicular lymph node hyperplasia and sometimes associated with polyneuropathy. We report 4 cases identified with diagnosis of Castleman's disease by lymph node biopsy and peripheral polyneuropathy. They had a hypesthesia of all limbs, gait disturbance, weakness of distal lower limbs and enlargement of lymph nodes. Among them 2 patients were combined with POEMS (polyneuropathy, organomegaly, endocrinopathy, increase of M protein, skin change) syndrome. Motor and sensory nerve conduction velocities were below 70% of lower normal limit, the amplitudes of compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) were reduced. Deterioration of nerve conduction study was more severe in lower limb than the upper. More denervation potentials were found in lower limbs than the upper and in distal limbs than the proximal. As disease getting worse, the slower conduction velocity and lower amplitude of CMAP and SNAP were observed.

The Pattern of Malnutrition in Cerebral Palsy and Relating Factors

OBJECTIVE: This study was undertaken to characterize the nutritional status, the status of growth and the relation to various factors in cerebral palsy. METHOD: Forty patients with cerebral palsy (20 quadriplegia, 20 diplegia) were investigated. Information was obtained from medical record, clinical measure and anthropometric measure (weight for height, triceps skinfolds thickness per age, height for age). Values of weight for height or triceps skinfold below the 2.5 percentile were defined as "undernutrition", values of height for age below the 2.5 percentile were defined as "growth retardation". Denver Developmental Screening Test (DDST) at the 12 months old and at the examined time, oromotor score, pattern of defecation, duration of gait per day of patients were interviewed from caregivers. Spasticity was measured by using Modified Ashworth's scale. RESULTS: Eleven children (27.5%) were in undernutrition state and 9 (22.5%) growth retardation. Oromotor dysfunction was positive in 62.5% and constipation in 30%. Less gait time, more severe oromotor dysfunction and fine motor delay in DDST and more quadriplegic type (p<0.05) were found in undernutrition group and no significant difference of spasticity and constipation. With logistic regression, quadriplegic type is the only significant factor to undernutrition. CONCLUSION: Undernutrition is common in cerebral palsy and quadriplegic type is significantly related to undernutrition.