Objective: To investigate the cortical disinhibition in diabetic patients with neuropathic pain and without pain. In addition, we assessed the cortical disinhibition and pain relief after repetitive transcranial magnetic stimulation (rTMS). Method: We recruited diabetic patients with neuropathic pain (n = 15) and without pain (n = 15). We compared the TMS parameters such as motor evoked potential (MEP) amplitude, cortical silent period (CSP), intracortical inhibition (ICI %) and intracortical facilitation (ICF %) between two groups. Moreover, we evaluated the changes of pain and TMS parameters after five consecutive high frequency (10 Hz) rTMS sessions in diabetic patients with neuropathic pain. The neuropathic pain intensity (visual analog scale) and TMS parameters were assessed on pre-rTMS, post-rTMS 1day, and post-rTMS 5 day. Results: The comparison of the CSP, ICI % revealed significant differences between two groups (p＜0.01). After rTMS sessions, the decrease in pain intensity across the three time points revealed a pattern of significant differences (p＜0.01). The change of CSP and ICI % across the three test points revealed a pattern of significant differences (p＜0.01). The ICI % revealed immediate increase after first rTMS application and significant increase after five rTMS application (p＜0.01) in diabetic patients with neuropathic pain. The MEP amplitude and ICF % did not reveal any significant changes. Conclusion: Our findings demonstrate that cortical inhibition was decreased in diabetic patients with neuropathic pain compared with patients without pain. Furthermore, we also identified that five daily rTMS sessions restored the defective intracortical inhibition which related to improvement of neuropathic pain in diabetic patients.

Objective: To determine the relationship between cervical sagittal parameters and the degree of the cervical disc degeneration at each cervical level by using cervical plain radiographs and disc degeneration grading. Method: This study analyzed 110 patients with posterior neck pain. Cervical radiographic measurements included the occipito-cervical (O∼C2) angle; sagittal Cobb angles of C1∼C2, C2∼C7; and sagittal vertical axis (SVA) of C1∼C7 and C2∼C7. The degenerations of cervical discs at each level were evaluated through Pfirrmann grading system by magnetic resonance images of the cervical spine. The correlations between the cervical sagittal measurements and the disc degeneration at each level were analyzed by Spearman’s correlation. Results: A significant correlation was found for the C2∼C7 angle with disc degenerations at C2∼C6 levels. O∼C2 angle was correlated significantly with disc degenerations at C2∼C4 and C5∼C7 levels. There was significant correlation between C1∼C2 angle and disc degeneration at C6∼C7 level. No significant relationship was found between the cervical SVA and the cervical disc degeneration at all cervical levels. Conclusion: Cervical sagittal parameters representing cervical angles (C2∼C7, O∼C2, and C1∼C2 angles) were significantly correlated with the degree of the cervical disc degeneration. These findings suggest that the loss of the natural cervical lordosis rather than loss of natural SVA could be correlated with progression of the cervical disc degeneration.

Objective: To evaluate the effectiveness of dynamic balance exercise after intra-articular injection of hyaluronic acid (HA) therapy in elderly patients with unilateral knee osteoarthritis. Method: 30 patients with unilateral knee osteoarthritis were enrolled in this study. The patients were randomly divided into two groups: dynamic balance exercise after HA injection group (group A) and only HA injection group (group B). Both groups administered intra-articular HA injection and group A patients continued 20-session exercises for 4 weeks. The assessments were measured before injection and 4 weeks after treatment using the visual analog scale (VAS) for pain, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) for physical function, Berg balance scale (BBS), and computerized dynamic posturography using SMART Balance Master system for balance function. Results: In both groups, significant improvements in VAS, WOMAC and balance function were observed. Compared between groups, group A showed significant improvements compared to group B in WOMAC and balance function. Conclusion: It is suggested that dynamic balance exercise may result in improved balance function and physical function in elderly patients with unilateral knee osteoarthritis.

Objective: Greater occipital nerve block (GONB) is a widely accepted treatment of primary headaches. Two ultrasound (US)-guided blockade techniques exist: 1) the classical distal nerve block technique performed medial to the occipital artery at the superior nuchal line, and 2) the new proximal nerve block technique performed at the obliquus capitis inferior muscle at the level of C2. Our study aim was to perform a head-to-head comparative study of these two US-guided techniques. Method: Forty-nine patients with primary headache treated in our university hospital were recruited. Patients were randomized into two groups of the classical nerve block and the new proximal nerve block techniques. The headache questionnaire was made to assess the intensity of the pain of headache attacks, number of days they experience headache, duration of headache, and amount of pain medication they consumed. Results: In both groups, a decrease in the severity and frequency of the headache was observed. There was no measurable difference in outcome between the two groups. Conclusion: Our study showed that the classic and new proximal techniques are equally effective in decreasing the headache severity and frequency.

Plantar heel pain is a common clinical problem in foot and ankle clinics. Typically, several conditions such as plantar fasciitis, fat pad atrophy, and calcaneal fracture may lead to plantar heel pain. However, subcalcaneal bursitis occurred between plantar fascia and plantar fat pad has rarely been described as a cause of plantar heel pain. To our knowledge, subcalcaneal bursitis has been reported only once, but there was no mention of preceding factors. We firstly present a case of subcalcaneal bursitis occurred after excessive walking exercise known as “Nordic walking” and successfully managed with conservative treatments that relieve impact on plantar heel.

Chronic postoperative inguinal pain (CPIP) is a major complication after inguinal herniorrhaphy. We report the treatment of CPIP using ultrasonography-combined with nerve stimulator for injection of the genitofemoral nerve (GFN). A 59-year-old man underwent laparoscopic herniorrhaphy and presented with numbness from the inguinal region to the scrotum after operation. In the pain clinic, ultrasonography-guided GFN block and pharmacological treatments had little effect. Six month after operation, patient was referred to the Department of Physical Medicine and Rehabilitation, and ultrasonography-combined with nerve stimulator for GFN injection underwent to enhance the accuracy of neural approach. The induction of scrotal contraction and paresthesia on the GFN distribution was monitored by nerve stimulator and local anesthetic was injected. After the block, pain relief lasted for 6 months without analgesic use. Ultrasonography-combined with nerve stimulator is an effective approach to treat CPIP as it enhances precise localization and injection of small peripheral nerve like GFN.

Carpal tunnel syndrome can be produced by abnormal mass effect due to trauma, ganglion cysts, various soft tissue tumors, musculotendinous variants, and aberrant vascular structures. Persistent median artery is one of the causes of the carpal tunnel syndrome. Thrombosed persistent median artery usually accompanies the anomaly of the median nerve and causes a sudden onset of severe pain and paresthesia. In contrast to previous literature, we report the rare case of gradual onset and mild symptom of a 53-year-old man with a thrombosed persistent median artery but without anomaly of the median nerve and abnormal finding of electrophysiologic study.

Lying on the side while falling asleep deeply after drinking or taking a sleeping pill can cause compressive neuropathy. We report a 70-year-old male patient of medial cord of left brachial plexus injury (BPI) after deep sleep. The mechanism of the injury might be compression and stretching of brachial plexus. The electrodiagnostic study was performed and the medial cord lesion of BPI was suggested. The ultrasonography image of compression site revealed the nerve swelling of medial cord of brachial plexus and median nerve at the mid-arm level. Pharmacologic treatment including oral prednisolone and exercise training were prescribed. On 6 months after initial visit, neurologic symptom and pain were improved but mild sequelae was remained.

Symmetrical proximal weakness and characteristic dermatologic manifestations are important in the diagnosis of dermatomyositis. We report a case of atypical presentation of dermatomyositis due to previous steroid use and also report steroid-induced myopathy which may occur from steroid administration during the course of treatment. A 77-year-old man, previous steroid user, showed rapidly progressing weakness after abruptly stopped medication. He has presented erythematous papule on face and anterior chest but no heliotrope rash and Gottron's papules were observed. Muscle enzyme (creatine kinase) concen-tration is increased, and needle electromyography shows increased spontaneous activity on proximal limb muscle. The muscle biopsy confirmed dermatomyositis. During the course of treatment, he revealed persistent weakness despite the continuous steroid use and stable creatine kinase level. Electrodiagnostic study suggests steroid-induced myopathy and after tapering steroid, proximal muscle strength improved. This case reports the effect of steroid use on dermatomyositis patients and a process of diagnosing coexisting steroid induced myopathy during treatment.

Spinal accessory neuropathy (SAN) is commonly caused by an iatrogenic procedure, and that caused by tumors is very rare. We present a case of a 49-year-old man suffering from weakness in the right trapezius and sternocleidomastoid muscle. An electrophysiology study confirmed proximal SAN. Fluorodeoxyglucose (FDG)–positron emission tomography (PET)/computed tomography (CT) revealed a diffuse large B-cell lymphoma compressing the right spinal accessory nerve. Ultrasonography showed definite atrophy on the trapezius and sternocleidomastoid muscles. In addition, post-chemotherapy FDG-PET/CT showed increased FDG uptake in the right upper trapezius, suggestive of denervation. This is the first report of SAN caused by direct compression by a diffuse large B-cell lymphoma, comprehensively assessed by an electrophysiology study, ultra-sonography, and FDG-PET/CT.