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To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome.
A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome.
The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving.
The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.
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To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.
Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.
Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion.
In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.
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To investigate the factors affecting prognosis of extracorporeal shockwave therapy (ESWT) for chronic refractory Achilles tendinopathy (AT).
Thirty-six patients (48 consecutive feet) with chronic AT (>6 months) and who underwent ESWT for ‘poor’ or ‘fair’ grade in Roles-Maudsley Score (RMS) after unsuccessful conservative treatment were included in the present study. A maximum of 12 sessions of ESWT were conducted until treatment success: RMS reached ‘good’ or ‘excellent’. Termination of ESWT for no response, or ‘poor’ or ‘fair’ grade was regarded as treatment failure. Immediate outcome, long-term outcome (telephone interview after mean 26 months), and factors affecting treatment success were analyzed.
Numeric Rating Scale was significantly decreased at immediate and long-term follow-up. Success rate was 71.1% and 90.3%, respectively. Univariate logistic regression identified that immediate treatment success was associated with retrocalcaneal enthesophyte on X-ray (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01–0.28), pretreatment abnormal ultrasonography echogenicity within Achilles tendon (OR, 18.89; 95% CI, 2.08–171.96), mean duration of ‘post-treatment soreness’ (OR, 0.55; 95% CI, 0.33–0.94), and duration of ‘post-treatment soreness after first ESWT’ (OR, 0.06; 95% CI, 0.01–0.34). The duration of ‘post-treatment soreness after first ESWT’ was found to be the only factor associated with long-term success (OR, 0.32; 95% CI, 0.10–0.99).
ESWT appears to be effective in achieving long-term success in chronic refractory AT. Immediate success was associated with absence of retrocalcaneal enthesophyte on X-ray, presence of pretreatment abnormal ultrasonography echogenicity, shorter mean duration of ‘post-treatment soreness’, and shorter duration of ‘post-treatment soreness after first ESWT’. The shorter duration of ‘post-treatment soreness after first ESWT’ was identified as the only positive prognostic parameter in achieving long-term success.
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To evaluate the effectiveness of lower energy flux density (EFD) extracorporeal shock wave therapy (ESWT) in the early stage of avascular necrosis (AVN) of the femoral head.
Nineteen patients and 30 hips were enrolled. All subjects received 4 weekly sessions of ESWT, at different energy levels; group A (n=15; 1,000 shocks/session, EFD per shock 0.12 mJ/mm2) and group B (n=15; 1,000 shocks/session, EFD per shock 0.32 mJ/mm2). We measured pain by using the visual analog scale (VAS), and disability by using the Harris hip score, Hip dysfunction and Osteoarthritis Outcome Score (HOOS), and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC). To determine the effect of the lower EFD ESWT, we assessed the VAS, Harris hip score, HOOS, WOMAC of the subjects before and at 1, 3, and 6 months.
In both groups, the VAS, Harris hip score, HOOS, and WOMAC scores improved over time (p<0.05).
Lower EFD ESWT may be an effective method to improve the function and to relieve pain in the early stage of AVN.
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To evaluate characteristics of static and dynamic parameters in patients with degenerative flat back (DFB) and to compare degree of their improvement between successful and unsuccessful surgical outcome groups
Forty-seven patients with DFB were included who took whole spine X-ray and three-dimensional motion analysis before and 6 months after corrective surgery. Forty-four subjects were selected as a control group. As static parameters, thoracic kyphosis (TK), thoracolumbar junction (TLJ), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured. As dynamic parameters, maximal and minimal angle of pelvic tilt, lower limb joints, and thoracic and lumbar vertebrae column (dynamic TK and LL) in sagittal plane were obtained.
The DFB group showed smaller TK and larger LL, pelvic posterior tilt, hip flexion, knee flexion, and ankle dorsiflexion than the control group. Most of these parameters were significantly corrected by fusion surgery. Dynamic spinal parameters correlated with static spinal parameters. The successful group obtained significant improvement in maximal and minimal dynamic LL than the unsuccessful group.
The DFB group showed characteristic lower limb and spinal angles in dynamic and static parameters. Correlation between static and dynamic parameters was found in spinal segment. Dynamic LL was good predictor of successful surgical outcomes.
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To compare the clinical outcomes following conservative treatment and arthroscopic repair in patients with a rotator cuff tear.
In this retrospective study, patients aged >50 years with a symptomatic rotator cuff tear were reviewed. The rotator cuff tendons were evaluated using ultrasonography, shoulder magnetic resonance imaging or MR arthrography, and the patients with either a high-grade partial-thickness or small-to-medium-sized (≤3 cm) full-thickness tear were included in this study. The primary outcome measures were a pain assessment score and range of motion (ROM) at 1-year follow-up. The secondary outcomes were the rate of tear progression or retear along with the rate of symptom aggravation after the treatments.
A total of 357 patients were enrolled, including 183 patients that received conservative treatment and 174 patients who received an arthroscopic repair. The pain assessment score (p<0.001) and the ROM in forward flexion (p<0.001) were significantly improved in both groups. The ROM in internal rotation did not significantly change after conservative treatment and arthroscopic repair. The pain assessment score and ROM were not significantly different between the two groups. Retear was observed in 9.6% of patients who had an arthroscopic repair and tear progression was found in 6.7% of those who underwent conservative treatment. The proportion of aggravation for pain and ROM did not significantly differ between the two groups.
The effectiveness of conservative treatment is not inferior to arthroscopic repair for patients >50 years old with a less than medium-sized rotator cuff tear in a 1-year follow-up period. Further study is warranted to find the optimal combination of conservative treatment for a symptomatic rotator cuff tear.
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To identify the correlation between change in spinal deformities after surgical release and age at the time of surgery, and the effectiveness of surgical release in patients with neglected congenital muscular torticollis (CMT).
This was a retrospective study of 46 subjects with neglected CMT who had undergone surgical release at age ≥5 years at a tertiary medical center between January 2009 and January 2014. Spinal deformities were measured on anteroposterior plain radiographs of the cervical and whole spine, both preoperatively and postoperatively, to assess 3 parameters: cervicomandibular angle (CMA), lateral shift (LS), and Cobb angle (CA). We analyzed the change in spinal deformities after surgical release in consideration of age at the time of surgery.
The median age at the time of surgery was 12.87 years. All 3 parameters showed significant improvement after surgical release (median values, pre- to post-surgery: CMA, 12.13° to 4.02°; LS, 18.13 mm to 13.55 mm; CA, 6.10° to 4.80°; all p<0.05). There was no significant correlation between age at the time of surgery and change in CMA (R=0.145, p=0.341) and LS (R=0.103, p=0.608). However, CA showed significant improvement with increasing age (R=0.150, p=0.046).
We assessed the correlation between change in spinal deformities after surgical release and age at the time of surgery. We found that that surgical release is effective for spinal deformities, even in older patients. These findings enhance our understanding of the effectiveness and timing of surgical release in patients with neglected CMT.
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To determine clinical and radiological factors that predict the successful outcome of percutaneous disc decompression (PDD) in patients with lumbar herniated nucleus pulposus (HNP).
We retrospectively reviewed the clinical and radiological features of patients who underwent lumbar PDD from April 2009 to March 2013. Sixty-nine patients with lumbar HNP were studied. Clinical outcome was assessed by the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). Multivariate logistic regression analysis was performed to assess relationship among clinical and radiological factors and the successful outcome of the PDD.
The VAS and the ODI decreased significantly at 1 year follow-up (p<0.01). One year after PDD, the reduction of the VAS (ΔVAS) was significantly greater in the patients with pain for <6 months (p=0.03) and subarticular HNP (p=0.015). The reduction of the ODI (ΔODI) was significantly greater in the patients with high intensity zone (p=0.04). Multivariate logistic regression analysis revealed the following 5 factors that were associated with the successful outcome after PDD: pain duration for <6 months (odds ratio [OR]=14.036; p=0.006), positive straight leg raising test (OR=8.425, p=0.014), the extruded HNP (OR=0.106, p=0.04), the sequestrated HNP (OR=0.037, p=0.026), and the subarticular HNP (OR=10.876, p=0.012).
PDD provided significant improvement of pain and disability of patients. The results of the analysis indicated that the duration of pain <6 months, positive straight leg raising test, the subarticular HNP, and the protruded HNP were predicting factors associated with the successful response of PDD in patients with lumbar HNP.
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To investigate the dose-related effects of extracorporeal shock wave therapy (ESWT) for knee osteoarthritis.
Seventy-five subjects were recruited, 60 of which met the inclusion criteria. The patients were randomly classified into two groups: group L, which was a low-energy group (n=30; 1,000 shocks/session; energy flux density [EFD], 0.040 mJ/mm2) and group M, which was a medium-energy group (n=30; 1,000 shocks/session; EFD, 0.093 mJ/mm2). For each group, 1,000 shock waves were delivered to the medial tibial plateau area, once a week, for 3 weeks. The main outcome measures were the visual analogue scale (VAS), the Roles and Maudsley (RM) score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and the Lequesne index. Each assessment was performed at the baseline and at 1, 4, and 12 weeks after ESWT.
In both groups, the VAS, the RM and WOMAC scores, and the Lequesne index were significantly improved over time (p<0.001), and group M showed greater improvement over group L at the 1, 4 and 12 weeks assessments.
In this study, medium-energy group (group M) showed greater improvement in regard to relieving pain and restoring functional outcome than the low-energy group (group L). Therefore, EFD can be considered to have significant influence when treating with ESWT for knee osteoarthritis.
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To confirm functional improvement in brain tumor patients after 4-week conventional rehabilitation therapy, to compare the cognitive impairment of brain tumor patients with subacute stroke patients using computerized neuropsychological testing, and to determine the effects on functional outcomes of daily activity.
From April 2008 to December 2012, 55 patients (29 brain tumor patients and 26 subacute stroke patients) were enrolled. All patients were assessed with a computerized neuropsychological test at baseline. Motricity Index, Korean version of Mini Mental Status Examination, and Korean version of Modified Barthel Index scores were assessed at the beginning and end of 4-week rehabilitation. Conventional rehabilitation therapy was applied to both groups for 4 weeks.
Functional outcomes of all patients in both groups significantly improved after 4-week rehabilitation therapy. In brain tumor patients, the initial Motricity Index, cognitive dysfunction, and visual continuous performance test correction numbers were strong predictors of initial daily activity function (R2=0.778, p<0.01). The final Motricity Index and word-black test were strong predictors of final daily activity function (R2=0.630, p<0.01). In patients with subacute stroke, the initial Motricity index was an independent predictor of initial daily activity function (R2=0.245, p=0.007). The initial daily activity function and color of color word test were strong predictors of final daily activity function (R2=0.745, p<0.01).
Conventional rehabilitation therapy induced functional improvement in brain tumor patients. Objective evaluation of cognitive function and comprehensive rehabilitation including focused cognitive training should be performed in brain tumor patients for improving their daily activity function.
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To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar fasciitis (PF) according to ultrasonography (US) findings.
Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups (Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity. Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS). ESWT (0.10 mJ/mm2, 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered as treatment success.
Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up.
If other causes of heel pain are ruled out through meticulous physical examination and ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate, however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.
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To translate the English version of the Pain Disability Questionnaire (PDQ) into Korean and to investigate the reliability and validity of the Korean version of the PDQ (K-PDQ) in patients suffering chronic disabling musculoskeletal disorders (CDMDs).
The English version of the PDQ was translated into Korean. Ten patients with CDMDs were randomly selected for a pilot study to assess the comprehensibility of the pre-final version. One hundred and thirty-nine patients suffering from CDMDs for more than 3 months were enrolled in this study. Follow-up questionnaires were obtained to examine the test-retest reliability. Concurrent validity was evaluated by comparing the K-PDQ with the visual analogue scale (VAS). Construct validity was evaluated by comparing the K-PDQ with the brief form of the World Health Organization quality of life assessment instrument (WHOQOL-BREF) using Pearson correlation coefficient. Reliability was assessed using the intraclass correlation coefficient (ICC), and internal consistency was determined by Cronbach's alpha.
Test-retest reliability was assessed in 70 patients, with an average time interval of 12 days. The ICC was 0.958 (p<0.001). Internal consistency reached Cronbach's alpha of 0.933 for the functional component and 0.870 for the psychosocial component. The correlation coefficient for the K-PDQ when compared with the VAS was 0.834 in the first assessment and 0.831 in the second assessment. All domains of the WHOQOL-BREF showed a significant negative correlation with the K-PDQ.
The K-PDQ is a reliable and valid instrument for measuring disability and can be used to assess disability and treatment outcomes in Korean patients with CDMD.
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