Opioids and Antidepressants for Pain Control in Musculoskeletal Disease / 대한정형외과학회잡지

The progression of aging and the increase in musculoskeletal diseases have led to an increase in invasive treatment methods, including various surgical methods, but conservative treatment should be attempted before surgical treatment in musculoskeletal diseases. Medication for pain control, such as acetaminophen, non-steroidal anti-inflammatory drugs, steroid, opioids, antidepressants, etc., is one of the most popular methods for pain control. If the pain receptors on peripheral organ are stimulated, pain is transmitted to the brain by the ascending pathway, and the brain then secretes endogenous opioids, such as endorphin, by the descending pathway for pain control. Opioids are substances that act on the opioid receptors, and there are three receptors for opioids. The affinity for each receptor varies according to the tissue and the patient's systemic status. Antidepressants work on the synapses in the central nervous system and its main mechanism is regulation of the ascending pathway. This is mainly effective in chronic pain and neuropathic pain, which is similar in effectiveness to opioids. This review focuses on the effectiveness, method of use, and side effects of opioids and antidepressants.

A Case of Early Gastric Cancer with Nodular Tumor-like Scalp Metastasis / 대한소화기학회지

Many neoplasms, including lung cancer, breast cancer, melanoma, and gastrointestinal tract malignancy, possess potential for skin metastasis. Skin metastases can represent the first presentation of such malignancies and may be observed incidentally during routine exam. Skin metastases from gastric adenocarcinoma are uncommon, with a prevalence rate of 0.04-0.8%. Cutaneous metastases from gastric cancer are generally observed as the initial symptom of advanced gastric cancer. Early detection and treatment can increase patient survival. A 42-year-old woman visited our department with nodule about 1 cm in size on the right frontal scalp noticed incidentally after laparoscopy-assisted distal gastrectomy and adjuvant systemic chemotherapy for early gastric cancer about 16 months prior. The patient was diagnosed with skin metastasis from gastric adenocarcinoma. Complete excision of the skin lesion and additional chemotherapy were performed. Herein, we report a case of nodular tumor-like scalp metastasis from early gastric cancer with a brief review of the literature.

Asymptomatic Gastric Band Erosion Detected during Routine Gastroduodenoscopy

The incidence of gastric band erosion has decreased to 1%. Gastric band erosion can manifest with various clinical symptoms, although some patients remain asymptomatic. We present a case of a mostly asymptomatic patient who was diagnosed with gastric band erosion during a routine health check-up. A 32-year-old man without any underlying diseases except for non-alcoholic fatty liver underwent laparoscopic adjustable gastric band surgery in 2010. He had no significant complications postoperatively. He underwent routine health check-ups with near-normal gastroduodenoscopic findings through 2014. However, in 2015, routine gastroduodenoscopy showed that the gastric band had eroded into the stomach. His gastric band was removed laparoscopically, and the remaining gastric ulcer perforation was repaired using an omental patch. Due to the early diagnosis, the infection was not serious. The patient was discharged on postoperative day 3 with oral antibiotics. This patient was fortunately diagnosed early by virtue of a routine health check-up; thus, eliminating the possibility of serious complications.

Comparing Self-Selected Speed Walking of the Elderly With Self-Selected Slow, Moderate, and Fast Speed Walking of Young Adults

OBJECTIVE: To find the characteristics of elderly gait, we compared the elderly walking at a moderate speed with the young adult walking at a slow, moderate, and fast speed. METHODS: 3D gait analysis was performed on 15 elderly and 15 young adults. Temporo-spatial, kinematic, and kinetic parameters were obtained. Self-selected moderate speed of the elderly walking was compared with self-selected varying speed of the young adults walking. RESULTS: The elderly walked at slower speeds and had shorter step length, but showed similar cadences compared to the young adults. These results remained identical even after the normalization with height. The kinematic and the kinetic graph patterns did not show specific differences between the elderly and the young subjects. Ankle plantarflexion (APF) motion was prominently decreased in the elderly subjects. Hip flexion (HF) motion remained within similar range for the young adults'. HF moment and power were similar with the young adults', but APF power and hip extension power were decreased in the elderly subjects'. CONCLUSION: A decreased APF motion and power were thought to be specific findings in the elderly walking. The preservation of HF motion and power could be considered a compensation mechanism or a modified neuromuscular pattern in the elderly. The characteristics of the elderly walking should be taken into account when planning rehabilitation strategies of elderly gait training and for future studies on the elderly population.

Usual Dose of Caffeine Has a Positive Effect on Somatosensory Related Postural Stability in Hemiparetic Stroke Patients

OBJECTIVE: To evaluate the effect of caffeine on balance control of hemiparetic stroke patients, we investigated the difference in postural stability before and after drinking coffee by observing changes in stability index (SI) from posturography. METHODS: Thirty patients with history of stroke and 15 age-matched healthy subjects participated in this study. Effect of group factor (of the control and stroke groups) and treatment factor (pre- and post-drinking of coffee) on SI were tested in three conditions: with eyes opened, with eyes closed, and with a pillow support. The effects of these factors on visual deprivation and somatosensory change of subjects were also tested. RESULTS: Under all conditions, SI was higher in the stroke group than in the control group. Under eyes-open condition, the treatment factor was not statistically significant. Under eyes-closed condition, the interaction between group and treatment factor was statistically significant. After the subjects drank coffee, SI in the control group was increased. However, SI in the stroke group was decreased. Under pillow-supported condition, the interaction between group and treatment factor appeared marginally significant. For visual deprivation effect, the interaction between treatment and group factor was statistically significant. After caffeine consumption, the visual deprivation effect was increased in control group but decreased in the stroke group. For somatosensory change effect, the interaction between group and treatment factor was not statistically significant. CONCLUSION: Postural stability of hemiparetic stroke patients related to somatosensory information was improved after intake of usual dose of caffeine.

Gait Characteristics of Transfemoral Amputees in Long Term Users of Poly Centric Knee

OBJECTIVE: To evaluate characteristic gait patterns of transfemoral amputees who have been using polycentric knee for a long time. METHOD: Subjects were 22 transfemoral amputees using prosthesis for 29.0 years and 23 age-matched healthy adults. The three-dimensional gait analysis was performed. Temporospatial, kinematic and kinetic parameters were measured. RESULTS: Cadence and walking velocity of amputees decreased (p<0.05). Single support period decreased in amputee limb. There were no significant differences in hip flexion moment and power. In amputated limb, knee flexion in loading response was not observed and ankle plantar flexion was less than sound limb and control group. Excessive compensations of amputee side hip joint were not significant. CONCLUSION: Long term polycentric knee unit transfemoral prosthesis users show asymmetry of gait pattern which can increase the risk of musculoskeletal problems. Epidemiologic investigation would be necessary for prevention and proper management.

Evaluation of enteral formulas for nutrition, health, and quality of life among stroke patients

Enteral nutritional support has been used via tube feeding for dysphagic stroke patients. We performed long and short term trials to evaluate the effects of commercial enteral nutritional supports on nutrition and health in stroke patients (mRS = 3~5) and quality of life in their caregivers. For a long term study, we recruited chronic (> or = 1 yrs) stroke patients (n = 6) and administered them 6 cans/day (1,200 kcal) of the commercial enteral formula N for 6 months according to IRB-approved protocol. We collected peripheral blood at 0, 2, 4 and 6 months. For a short term study, we recruited acute (< or = 3 months) stroke patients (n = 12) and randomly administered them two different commercial enteral formulas, N or J, for 2 weeks. We collected their blood at 0, 4, 7 and 14 day of the administration. Blood samples were analyzed to quantify 19 health and nutritional biomarkers and an oxidative stress biomarker, malondialdehyde (MDA). In order to evaluate quality of life, we also obtained the sense of competence questionnaire (SCQ) from all caregivers at 'before' and 'after trials'. As results, the enteral formula, N, improved hemoglobin and hematocrit levels in the long term trial and maintained most of biomarkers within normal ranges. The SCQ levels of caregivers were improved in the long term treatment (P < 0.05). In a case of the short term study, both of enteral formulas were helpful to maintain nutritional status of the patients. In addition, MDA levels were decreased in the acute patients following formula consumption (0.05 < P < 0.1). Most of health and nutrition outcomes were not different, even though there is a big difference in price of the two products. Thus, we evaluate the formula N has equal nutritional efficacy compared to the formula J. In addition, long term use of enteral formula N can be useful to health and nutrition of stroke patients, and the quality of life for their caregivers.

Mean Values and Correlations between Rotational Profiles of Bilateral Lower Extremities in Korean Elderly Men

0OBJECTIVE: To investigate the mean values and correlations between the rotational profiles of bilateral lower extremities in Korean elderly men. METHOD: 100 lower extremities were examined for the rotational profiles of bilateral lower extremities with radiographic examination. RESULTS: The mean values of femoral anteversion, axial rotation of the knee joint, proximal and distal tibial torsion, bimalleolar axis (BMA), and Q angle were 8.72degrees, 0.19degrees, 34.53degrees, 26.25degrees, 20.97degrees, 5.65degrees. In Korean elderly men, the result of tibial torsion and Q angle was smaller than the results of other studies, and the bilateral differences were detected in the measured profiles of lower extremities, except axial rotation of the knee joint. However, all profiles represented a positive correlation between right and left lower extremities. The correlation between proximal tibial torsion and BMA had a positive correlation, But the femoral anteversion and tibial torsion had no correlations among the profiles in Korean elderly men. CONCLUSION: We suspected that Korean elderly healthy men have reduced tibial torsion and more genu varus alignment, and the rotational profiles of lower extremities showed side to side difference, but there were symmetrical tendency. It will be helpful in assessing the evaluation, treating, researching of the musculoskeletal problem in Korean elderly people.

Importance of Sensory Latency Measurement in Early Diabetic Polyneuropathy

OBJECTIVE: To evaluate the correlation between the variables of sensory nerve conduction study of diabetic polyneuropathy patients and the factors that explain variations of multivariate data of sensory nerve conduction study. METHOD: Forty four early diabetic polyneuropathy patients and forty normal control people were included in our study. Early polyneuropathy patients were diagnosed by nerve conduction study. Their sensory nerve conduction meaurement variables were compared with normal control people in terms of correlation between amplitude and latency, and factors that were independent. RESULTS: Age controlled partial correlations between amplitude and latency suggested that early diabetic polyneuropathy patients had more association between amplitude and latency than normal control people. Cannonical correlation also reinforced the above suggestion. Factor analysis revealed degenerative factor, demyelination factor, axonopathy factors that were independent in normal control people and degenerative factors, upper extremity demyelination factor, lower extremity functional factors in the dibetic polyneuropathy patients. CONCLUSION: The latency of sensory nerve conduction study was an important variable in assessing diabetic polyneuropathy patients.

Ultrasonographic Findings of Median Nerve Change according to the Wrist Position

OBJECTIVE: To assess the changes of ultrasonographic findings of median nerve according to wrist position change in normal and carpal tunnel syndrome hands. METHOD: We studied 31 carpal tunnel syndrome and 34 normal hands that were diagnosed by nerve conduction study and evaluated crossectional area, flattening ratio and distance to ulnar artery with diagnostic ultrasound. The parameters were tested according to the change of wrist position with neutral, extension and flexion in normal control and carpal tunnel syndrome. RESULTS: Crossectional area of carpal tunnel syndrome was larger than that of control. Flattening ratio of carpal tunnel syndrome was larger than that of control at extended position. Flattening ratio was greater in neutral and extended position than flexed position in carpal tunnel syndrome. Distance to ulnar artery were greater in flexed position than other positions in carpal tunnel syndrome. Frequency of least flattening ratio at flexion position in carpal tunnel syndrome was 64.52% and frequency of longest distance to ulnar artery at flexion position was 58.05%. CONCLUSION: Ultrasonography of median nerve showed no consistent findings according to change of wrist position between control and patients. Ultrasonographic diagnosis of carpal tunnel syndrome need further study for anatomical variations.

The Comparison of Therapeutic Effect of Shoulder Pain with Simple and Mixed Type in Patients with Adhesive Capsulitis

OBJECTIVE: This study was designed to divide the patients with adhesive capsulitis into two groups by ultrasonographic findings, such as simple capsulitis and mixed capsulitis patients and to compare the improvement of range of motion and shoulder pain in one month. METHOD: We examined 50 patients with adhesive capsulitis diagnosed by physical examination. In accordance to ultrasonographic findings, we divided the patients into two groups such as capsulitis and mixed capsulitis in patients with adhesive capsulitis. We treated shoulder pain by intraarticular injection and medication. We examined the range of motion of shoulder and visual analogue scale at each visiting time in a month. RESULTS: The mean age of patients was 55.3 (range: 39~77) years. There were 26 patients with simple capsulitis and 24 patients with mixed capsulitis. The average duration of pain was 16.1+/-23.9 months. There was meaningful difference of shoulder range of motion and visual analogue scale between pretreatment and posttreatment in patients with simple capsulitis and mixed capsulitis. But, there was no meaningful difference of shoulder range of motion and visual analogue scale between two groups. CONCLUSION: No specific difference was noted between the simple and the complex groups of adhesive capsulitis in the effect of treatment.

The Effects of Vibration Baths on Abdominal Fat and Blood Lipid Profile in Obese Women

BACKGROUND: Abdominal obesity is recognized as an important risk factor of metabolic diseases and atherosclerosis. The purpose of this study was to investigate the effects of vibration baths on abdominal fat and blood lipid profiles in obese women. METHODS: From Apr. to Jun 2000, the 32 obese women received vibration baths for 4 weeks (30 minutes/day, repeated 5 times per week). The people were divided randomly into two groups, the case (n=17) and the control (n=15) group. The case group received vibration baths (55 Hz) and the control group took baths only. Body weight, height, body mass index (BMI), body fat distribution, lipid profiles, and blood pressures were measured in all subjects immediately before and after 4 weeks of the study. The body fat distribution was assessed by CT scan by which both total abdominal and visceral fat areas were measured at the level of the umbilicus. RESULTS: After 4 weeks, 13 subjects remained in both groups, respectively, and the total abdominal and visceral fat area decreased significantly in the case group compared from those of the control group. There were no significant differences in body weight, body fat mass, serum lipid profiles, and blood pressures before and after the baths in the two groups. CONCLUSIONS: These results suggest that vibration baths is effective in decreasing abdominal fat. But there were no significant weight change, the effect is insufficient in obesity treatment goal.

The Correlation between Plasma Leptin Concentration and Adiposity in Obesity

BACKGROUND: Obesity can be considered as hyperaccumulation of body fat. Therefore, the aim to treat obesity is to decrease body fat. Abdominal total fat calculated in computed tomography is thought to be the most accurate index measuring body fat. The body mass index (BMI) and body fat mass are the representative indices also. Leptin is a protein hormone expressed by obesity gene in adipose tissue. It inhibits food intake and increases energy consumption, thereby controls obesity. With a study of relationship between plasma leptin level and body mass index and abdominal total fat area, we tried to find the usefulness of leptin as an index of adiposity. METHODS: The adiposity level was approximated by BMI, computed tomography and bioelectical impedence. To further explore the relationship with body composition, body fat distribution was determined by computed tomograph. To quantify the relationship between serum leptin level and adiposity, correlation analyses have been conducted. RESULTS: The subjects were 32 females with a BMI of over 25 kg/m2. The mean plasma leptin level was 14.2 5.9 ug/L. We investigated the correlation of plasma leptin level with subcutaneous and visceral fat. The plasma leptin level showed a significant correlation with BMI and body fat mass, and was significantly correlated with subctaneous fat (P<0.01), but not with abdominal visceral fat. CONCLUSION: A significant correlation between plasma leptin level and body fat mass was observed. The distribution of subcutaneous fat showed differences in plasma leptin level. Therefore, the plasma leptin level may be used as an index of change of body fat mass, especially subcutaneous fat.

Electrodiagnosis of Carpal Tunnel Syndrome in Patients with Diabetic Neuropathy

OBJECTIVE: To investigate the reliability of distoproximal latency ratio of median sensory nerve as a diagnostic criterion of carpal tunnel syndrome (CTS) in patients with diabetic polyneuropathy. SUBJECT: Electrophysiologic study was performed in 264 hands of 208 patients with diabetes. Forty eight hands (24 subjects) without diabetes mellitus or CTS were included as a normal control group. Another 48 hands having CTS without diabetes mellitus were also included as a CTS control group. METHOD: Clinical and electrophysiologic findings were included to detect carpal tunnel syndrome in patients with diabetic neuropathy. Sensitivity and specificity of various electrodiagnostic parameters to confirm clinical CTS were obtained. RESULTS: Diabetic neuropathy was diagnosed in 66.3%, and median neuropathy was diagnosed in 52.7%. CTS was found in 32.2% as determined by the distoproximal latency ratio. The sensitivity of distoproximal latency ratio as a diagnostic tool for CTS was the highest (95.1%) and the specificity was the second highest (51.3%) among 5 different electrodiagnostic criteria of CTS. CONCLUSION: The results suggest that distoproximal latency ratio is an important parameter with high sensitivity in determining CTS in the patients with diabetic polyneuropathy.

Influencing Psychologic Factors and Stress in Patients with Chronic Pain

OBJECTIVE: To investigate the influence of psychologic factors and stress on chronic pain syndrome and predictive factors of chronic pain. METHOD: The subjects were 23 patients with chronic pain. The age was ranged from 25 to 66 years with an average of 45. We measured pain with initial visual analogue scale (VAS), one-week total VAS, and tenderness threshold by pressure algometer. We evaluated the degree of depression, anxiety and disability with chronic pain and the impact of stress of major versus minor daily events. Association between degree of pain and psychologic factors was studied by regression and stress of major versus minor daily events by correlation analysis. Predictive factors for chronic pain were determined by multiple regression analysis. Association of daily fluctuation of pain severity and stress from minor life events was also studied. RESULTS: One-week total VAS was associated with initial VAS (r=0.601, p<0.05). Initial VAS had association with depression and anxiety. Predictive factors for one-week total VAS were initial VAS, static anxiety, and pain disability (r=0.624, p<0.05). CONCLUSION: Depression, anxiety, pain disability from chronic pain, and stress were major influencing factors in patients with chronic pain.

Hyperactive Stretch Reflexes as a Prognostic Factor of Ambulation in the Children with Spastic Diplegia

OBJECTIVE: The purpose of this study was to investigate the influence of hyperactive stretch reflexes and contralateral adductor spread on the prognosis of gait in cerebral palsy with spastic diplegia and to investigate the reflex characteristics of spastic patients according to motor development. METHOD: Thirty three children with spastic diplegia were examined. Compound muscle action potentials elicited by electrical hammer were used for quantification of stretch reflexes. Clinical spasticity was evaluated with the modified Ashworth scale and re-evaluation was done at least for 18 months. The patients were classified as 3 groups according to the stage of motor development: Group I consisted of children who were unable to sit; Group II children were able to pull to stand but unable to walk independently; Group III children could walk independently more than ten steps. Reflex irradiation, amplitudes of compound muscle action potentials, amplitude ratios, and Ashworth scores were analyzed and compared between the groups. Twenty four normal infants and 18 children were examined as control. RESULTS: Contralateral adductor responses were elicited with patellar tendon tap stimulation in all spastic diplegic children. The amplitudes of contralateral adductor were 2.41 mV in group I, 1.75 mV in group II, and 1.21 mV in group III. The amplitude ratio of contralateral adductor to rectus femoris were 0.53 in group I, 0.40 in group II, and 0.26 in group III, respectively, and correlated with the degree of spasticity. CONCLUSION: The stretch reflex responses in children with cerebral palsy with spastic diplegia were highly exaggerated, and correlated with motor development. Spread of reflexes to contralateral adductor muscle would be in clinical and electrophysiological value.

Analysis of Increased Myotatic Reflex in Children with Spastic Cerebral Palsy

OBJECTIVE: The purpose of this study was to analyse the myotatic reflex characteristics of children with spastic cerebral palsy compared with normal infants and children. METHOD: Thirty four children with spastic cerebral palsy and 42 normal children were examined. The tendon taps were applied to the patellar and Achilles' tendons and shin using an electric reflex hammer. Compound muscle action potentials (CMAPs) were recorded from hamstring (HAM), rectus femoris (RF), tibialis anterior (TA), and gastrocnemias (GCL) by surface electrodes. The response ratios of HAMs/RF and TA/GCL were determined from CMAP amplitude. RESULTS: The mean HAM/RF ratios after patellar taps were 0.32+/- 0.33, 0.37 +/-0.33 and 0.32+/- 0.19 in children with cerebral palsy, normal infants, and children over 1 year of age, respectively. The mean TA/GCL ratios following Achilles tap were 0.40 +/- 0.30, 0.93+/- 0.11, and 0.25+/- 0.14 in children with cerebral palsy, normal infants, and children over 1 year of age, respectively. All the spastic cerebral palsy children showed muscle responses in RF, HAM, TA and GCL after shin tap, but normal children did not. CONCLUSION: The results reflect that the reflex responses are exaggerated in children with spastic cerebral palsy, and it can be used in the early diagnosis of cerebral palsy.

Visual Evoked Potentials in Premature Infants

Visual evoked potentials(VEPs) are the cerebral electrical activities recorded from the occipital scalp following a flash or pattern stimulation and can detect the lesions of sensory visual pathways. Although the VEPs change with the maturation of CNS in children, a few studies have documented the maturational changes in premature infants. Using the light- emitting diode goggles, VEPs were studied in 131 neurologically intact infants of 28~41 weeks gestational age or 34~59 weeks postmenstrual age. The VEPs were analysed by three waveforms; normal, abnormal, and flat, and four patterns; N300, P200-N300, P100-N155-P200-N300, and P100 pattern. Normal waveforms were 63 of 131 VEPs(48.1%). Of the normal waveforms, N300 patterns were 38.1%, P200-N300 36.5%, P100-N155-P200-N300 19.0%, and P100 6.4%. Each pattern correlated with the postmenstrual age. These findings support the hypothesis of VEP pattern changes according to the maturation of the visual system with age.

Median Motor Nerve Conduction and H-reflex Studies in Premature Infants

Many factors have been identified which to affect the rate of propagation of impulses along motor fibers. These include temperature changes around the nerve, diameter of the axon, degree of myelinization, age of infants, and local environment of the nerve. Motor nerve conduction velocity and Hoffman's reflex latency have been used to assess the degree of myelination and maturation of the nervous system. The conduction velocities in infants of a short gestational age are significantly lower than those of the fullterm infants. The extrauterine myelination and maturation might increase nerve conduction velocity. We measure the median motor nerve conduction velocity, compound muscle action potentials amplitude and H-reflex latency of premature infants to determine the neurological maturation after birth. The premature infants with gestational age above 37 weeks have a significantly higher conduction velocity and a shorter H-reflex latency than those of gestational age below 37 weeks. The premature infants with weight over 2.5 kg have a significantly higher conduction velocity, larger compound muscle action potentials amplitude and a shorter H-reflex latency than those of weight below 2.5 kg. And there is a statistically significant negative correlation of the H-reflex latency with the postmenstrual age. The determination of motor nerve conduction velocities and H-reflex latencies seem to be an additional method in assessing the degree of maturity in infants after birth.

Clinical Evaluation of Diabetic Neuropahty

The purpose of this study was to evaluate clinical features of diabetic neuropahty. The clinical symptoms and signs were investigated in individuals with diabetes mellitus by a questionnaire of 17 items about motor, sensory, and autonomic symptoms and signs, and then electrodiagnostic study was performed. One hundred and one patients with diabetes mellitus aged 31 to 88 years participated. The most frequent complaint was tingling sensation in the distal extremities and the most frequent sign was decreased or absent ankle jerk. The least frequent symtom or sign was motor weakness. Eighty point two percent of patients showed electrodiagnostic abnormalities. Abnormal ankle jerk, tingling sensation, and paresthesia in patients with abnormal electrodiagnstic study were 60.5%, 58.0%, and 29.6%, respectively. Clinical diabetic neuropahty was diagnosed of the patients when both tingling sensation and decreased ankle jerk were present. We conclude that clinical symptoms and signs of diabetes mellitus may be useful for diagnosis of diabetic neuropathy.