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Cilt - Volume 29 Sayı - Number 2 Nisan - April 2017

ISSN 1300-0012

A RI PAIN TÜRK ALGOLOJİ (AĞRI) DERNEĞİ’NİN YAYIN ORGANIDIR THE JOURNAL OF THE TURKISH SOCIETY OF ALGOLOGY

Index Medicus-Medline, Web of Science, ESCI, EMBASE/Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir. (Included and Indexed in Index Medicus-Medline, Web of Science, ESCI, EMBASE / Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL and the Turkish Medical Index).

www.agridergisi.com


www.abdiibrahim.com.tr

Ağrı Nöropatikse Alyse

ETKİN MADDE: Her kapsül etkin madde olarak 25/75/150/300 mg pregabalin içerir. Pregabalin, GABA analoğu olan bir antiepileptiktir.Pregabalin SSS’ndeki voltaja duyarlı kalsiyum kanallarının yardımcı alt ünitesine (a2-d proteini) bağlanarak etki gösterir. ENDİKASYONLAR: Nöropatik Ağrı: ALYSE (pregabalin) periferik nöropatik ağrıda endikedir. ALYSE (pregabalin) fibromiyalji tedavisinde endikedir. Epilepsi: ALYSE (pregabalin) sekonder jeneralize konvülsiyonların eşlik ettiği ya da etmediği parsiyel konvülsiyonlu yetişkin hastalarda ek tedavi olarak endikedir. Fibromiyalji: ALYSE (pregabalin) fibromiyalji tedavisinde endikedir. Yaygın Anksiyete Bozukluğu: ALYSE (pregabalin) yaygın anksiyete bozukluğunda endikedir. KULLANIM ŞEKLİ VE DOZU: Günlük doz aralığı 150-600 mg aç ya da tok karnına alınabilir. Nöropatik Ağrı: Önerilen başlangıç dozu günde iki kez 75 mg'dır (150 mg/gün). Her bir hastanın yanıtına ve tolere edilebilirliğine göre doz, 3 ila 7 günlük bir aralıktan sonra günde iki kez 150 mg'a ve gerekirse, ek bir haftadan sonra günde iki kez 300 mg'lık maksimum doza çıkartılabilir. Epilepsi :Önerilen başlangıç dozu günde iki kez 75 mg'dır (150 mg/gün). Her bir hastanın yanıtına ve tolere edilebilirliğine göre doz, 1 haftadan sonra günde iki kez 150 mg'a ve gerekirse, ek bir haftadan sonra günde iki kez 300 mg'lık maksimum doza çıkartılabilir. ALYSE (pregabalin) tedavisi günlük 150 mg dozunda başlatılabilir. Yaygın Anksiyete Bozukluğu: Doz aralığı ikiye bölünmüş dozlar halinde, günlük 150-600 mg'dır. Fibromiyalji: Önerilen doz 300-450 mg/gün şeklindedir. Başlangıç dozu günde iki kez 75 mg’dır (150 mg/gün). Etkinlik ve tolerabiliteye göre 1 hafta içinde doz günde iki kez 150 mg (300 mg/gün) ve tedavide yeterli yanıt alınmazsa 450 mg/gün şeklinde artırılabilir. Nöropatik ağrı, epilepsi veya yaygın anksiyete bozukluğu için uygulanan pregabalin tedavisinin sona erdirilmesi gerekirse, en az bir haftaya yayılarak, kademeli şekilde sonlandırılması tavsiye edilir. Pregabalin sistemik dolaşımdan başlıca renal yolla değişmemiş ilaç şeklinde atılır. Renal fonksiyonları yetersiz hastalarda doz kreatinin klerensine göre bireyselleştirilmelidir. Pregabalinin 12 yaş altı pediyatrik hastalarda ve adolesanlarda (12-17 yaş arası) kullanımı önerilmez. Böbrek fonksiyonları normal olan yaşlı hastalarda herhangi bir doz ayarlamasına gerek yoktur. KONTRENDİKASYONLAR: Etken maddeye veya içeriğindeki herhangi bir maddeye karşı aşırı duyarlılığı olan hastalarda kontrendikedir. ÖZEL KULLANIM UYARILARI VE ÖNLEMLERİ: Antiepileptik ilaçlarla tedavi edilen hastalar intihar düşüncesi ve davranışı açısından yakından izlenmelidir. Pregabalin tedavisi nedeniyle kilo artışı görülen diyabet hastalarında, hipoglisemik ilaçların dozu tekrar gözden geçirilmelidir. Anjiyoödem belirtileri ortaya çıkarsa pregabalin derhal kesilmelidir. Pregabalin tedavisi, somnolans (uyku hali) ve baş dönmesine neden olabileceğinden, yaşlı hastalarda kaza sonucu yaralanmaların (düşme) oranını artırabilir. Hastalarda geçici olarak görmede bulanıklık ve görme netliğinde başka değişiklikler bildirilmiştir. Şiddetli konjestif kalp yetmezliği olan hastalarda pregabalin dikkatle kullanılmalıdır. Pregabalin ve tiazolidindionun birlikte uygulandığı hastalarda periferik ödem ve kilo artışının görülme sıklığı artabilir. Pregabalin baş dönmesi ve uyku haline neden olabilir. Bu nedenle, ilacın bu gibi aktiviteleri etkileyip etkilemediği bilinene kadar, hastalara araba kullanmaları, karmaşık makineleri çalıştırmaları veya tehlike potansiyeli barındıran başka aktivitelerde bulunmaları tavsiye edilmez. Gebelik ve Laktasyon: Gebelik kategorisi C’dir. Anneye sağlayacağı yarar fetüse gelebilecek risk potansiyelinden fazla olmadıkça, gebelik sırasında pregabalin kullanılmamalıdır. Pregabalin tedavisi süresince emzirme tavsiye edilmez. İSTENMEYEN ETKİLER: En yaygın şekilde bildirilen advers reaksiyonlar baş dönmesi ve uyku halidir. Advers etkiler genelde hafif ve orta şiddettedir. Diğer bildirilen yan etkiler; İştah artışı, periferik ödem, konfüzyon, dezoryantasyon, irritabilite, öfori hali, libidoda azalma, insomnia, Ataksi, koordinasyon bozukluğu, denge bozukluğu, amnezi, dikkat kaybı, hafıza bozukluğu, tremor, dizartri, parestezi, sedasyon, letarji, bulanık görme, diplopi, vertigo, kusma, abdominal şişkinlik, konstipasyon, ağız kuruluğu, gaz, erektil disfonksiyon, ödem, yürüyüşte anormallik, sarhoşluk hissi, anormallik hissi, yorgunluk, kilo artışıdır. İLAÇ ETKİLEŞİMLERİ: Pregabalin çoğunlukla farmakokinetik etkileşim olasılığı düşüktür. Pazarlama sonrası deneyimlerde, pregabalin ve diğer SSS’ni baskılayan ilaçları alan hastalarda solunum yetmezliği ve koma rapor edilmiştir. Pregabalin, kognitif ve gros motor fonksiyonlarda oksikodonun yol açtığı bozukluğa katkı sağlar gibi görünmektedir. Pregabalinin opioid analjezikler gibi konstipasyona sebep olabilecek ilaçlarla birlikte alınması sonucu alt gastrointestinal kanal fonksiyonlarında azalma bildirilmiştir. DOZ AŞIMI VE TEDAVİSİ: 15 g’a kadar olan doz aşımlarında, beklenmeyen bir advers etki bildirilmemiştir. Pregabalin doz aşımının tedavisinde genel destekleyici önlemler alınmalı, gerekirse hemodiyalize de başvurulmalıdır. TİCARİ TAKDİM ŞEKLİ: Alyse 25 mg / 150 mg/300 mg PVC/PVDC/Al blisterde 56 kapsül / Alyse 75 mg 14 kapsül RUHSAT TARİHİ VE NO: 25 mg;21/04/2011, 231/17 75 mg;21/04/2011, 231/19 150 mg; 21/04/2011, 231/16 300 mg;21/04/2011, 231/18 PERAKENDE SATIŞ FİYATI: Alyse 25 mg 56 Kapsül; 17,61 TL, Alyse 75 mg 14 Kapsül; 13,22 TL, Alyse 150 mg 56 Kapsül; 71,22 TL, Alyse 300 mg 56 Kapsül; 109,13 TL. (Şubat 2017) Reçete ile satılır. RUHSAT SAHİBİ: Abdi İbrahim İlaç San. ve Tic. A.Ş. Reşitpaşa Mah. Eski Büyükdere Cad. No: 4 34467 Maslak /Sarıyer/ İSTANBUL Tel: 0212 366 84 00 Faks: 0212 276 20 20 Detaylı bilgi için lütfen firmamıza başvurunuz. www.abdiibrahim.com.tr


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Editör (Editor-in-Chief ) Gül KÖKNEL TALU Bilimsel Danışma Kurulu (Editorial Board) Akyüz G Antonaci F Aydınlı I Babacan A Cahana A Çamcı E Erdine S Ertaş M Güldoğuş F Güleç S Hartrick C Heavner J Kapurol L

Turkey Italy Turkey Turkey Switzerland Turkey Turkey Turkey Turkey Turkey USA USA USA

Ketenci A Turkey Kress H Austria Önal A Turkey Raj PP USA Şentürk M Turkey Talu U Turkey Tan E Turkey Uyar M Turkey Vadalouca A Greece van Kleef M Netherlands Netherlands Vissers K Yücel B Turkey


Cilt (Volume) 29, Sayı (Number) 2, Nisan (April) 2017 p-ISSN 1300 - 0012 e-ISSN 2458-9446 Türk Algoloji (Ağrı) Derneği’nin Yayın Organıdır (The Journal of the Turkish Society of Algology)

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Üç Ayda Bir Yayınlanır (Published Quarterly) Sahibi ve Yazı İşleri Müdürü (Ownership and Accountability for Contents) Gül KÖKNEL TALU Türk Algoloji (Ağrı) Derneği The Turkish Society of Algology Başkan (President)

N. Süleyman ÖZYALÇIN

Üyeler (Members)

N. Süleyman ÖZYALÇIN Sema TUNCER UZUN Kenan AKGÜN Levent Ertuğrul İNAN Osman Nuri AYDIN Güngör Enver ÖZGENCİL Hayri Tevfik ÖZBEK

İletişim (Correspondence) Editör ve Yazı İşleri Müdürü (Editor-in Chief)

Gül KÖKNEL TALU

Yürütücü Sekreter (Executive Secretary)

Gül KÖKNEL TALU

Adres (Mailing Address) Tel (Phone) Faks (Fax) e-posta (e-mail) web

İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Algoloji Bilim Dalı, Çapa 34390 İstanbul, Turkey +90 - 212 - 531 31 47 +90 - 212 - 631 05 41 gktalu@yahoo.com www.algoloji.org.tr

Index Medicus-Medline, Web of Science, ESCI, EMBASE/Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir. (Included and Indexed in Index Medicus-Medline, Web of Science, ESCI, EMBASE / Excerpta Medica, Index Copernicus, Gale, EBSCO, CINAHL and the Turkish Medical Index).

Yayıncı (Publisher) KARE YAYINCILIK | karepublishing

KARE Altayçeşme Mah. Engin Sok. No: 3 / 20 34843 Maltepe, İstanbul, Turkey Tel: +90 216 550 61 11 Faks (Fax): +90 216 550 61 12 e-posta (e-mail): kareyayincilik@gmail.com / kare@kareyayincilik.com www.kareyayincilik.com Yayın Türü (Type of Publication): Süreli Yayın (Periodical) Basım Tarihi (Press Date): Nisan 2017 (April 2017) Sayfa Tasarımı (Design): Ali CANGÜL Baskı (Press): Yıldırım Matbaacılık Online Dergi (Web): LookUs Baskı Adedi (Circulation): 300

www.agridergisi.com

Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur (This publication is printed on paper that meets the international standart ISO 9706: 1994)


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Yazarlara Bilgi Information for the Authors

DERLEME R E V I E W 51–54

Pain in women Kadınlarda ağrı Belfer I

KLİNİK VE DENEYSEL ÇALIŞMALAR ORIGINAL AND EXPERIMENTAL ARTICLES 55–63

Coping with the pain of elderly pain patients: Nursing approach Geriatrik ağrı hastalarının ağrıyla başa çıkma durumları: Hemşirelik yaklaşımı Babadağ B, Balcı Alparslan G, Güleç S

64–70

Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain: Comparison of monopolar and bipolar modes Alt ekstremitenin iskemik ağrı tedavisinde radyofrekans termokoagülasyon: Monopolar ve bipolar modların karşılaştırması Destegül D, Işık G, Özbek H, ÜnlügençH, Ilgınel M

71–78

Prevalence of and risk factors for low back pain among healthcare workers in Denizli Denizli’de sağlık çalışanlarında bel ağrısı prevelansı ve risk faktörleri Şimşek Ş, Yağcı N, Şenol H

OLGU SUNUMLARI CASE REPORTS 79–81

Primary headache associated with sexual activity: A case report Seksüel aktivite ile ilişkili primer baş ağrısı: Olgu sunumu Özcan T, Yancar Demir E, İşcanlı MD

82–85

Analjeziklere dirençli kronik baş ağrısının nadir bir nedeni: İzole sfenoid sinüs aspergilloması A rare cause of analgesic-resistant chronic headache: isolated aspergilloma of the sphenoid sinus Günbey E, Aslan K, Günbey HP, Karlı R, Kardaş Ş

86–89

Antihistaminik kullanımı ile tetiklenen tekrarlayıcı baş ağrısı ve reversible serebral vazokonstriksiyon sendromu Reversible cerebral vasoconstriction syndrome and recurrent headache triggered by antihistamine use Güler S, Utku U, Çelebi C

EDİTÖRE MEKTUP LETTER TO THE EDITOR 90–91

An unusual complication of anesthesia: Unilateral spinal myoclonus Anestezinin olağandışı bir komplikasyonu: Tek taraflı spinal miyoklonus Kösem B, Kılınç H

92–93

Sonoanatomic variation of the vasculature at infraclavicular region İnfraklavikular bölgede vaskülatürün sonokanatomik varyasyonu Balaban O, İtal İ, Aydın E, Korkmaz M, Aydın T

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İLGİ ALANI VE AMACI Bu dergi Türk Algoloji (Ağrı) Derneği’nin süreli yayın organıdır. Üç ayda bir yayımlanır. Ağrının yapısı, mekanizmaları ve tedavisi ile ilgili özgün araştırmalar yayınlanır. Multidisipliner bir yaklaşım ile ağrı ile ilgili temel ve klinik bilimlerde yapılan araştırmaların geniş kitlelere yayılması için bir forum oluşturulmaya çalışılır. GENEL AÇIKLAMALAR 1. Dergi Türkçe ve İngilizce olarak yayınlanır. 2. Editoryal Kurul tarafından uygun görülen metinler yayımlanır. Editoryal Kurul, yayın kurallarına uymayan metinleri yayımlamamaya ve düzeltilmek üzere yazarına geri göndermeye yetkilidir. “Derleme” kategorisindeki yazılar, Editoryal Kurul tarafından belirlenen yazarlardan yapılan istek üzerine kabul edilmektedir. Editoryal Kurul tarafından istenmedikçe bu kategoriler için yazı gönderilmemelidir. Ancak bu konuda editöre öneride bulunulabilir. Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. 3. Dergi, uluslararası tıbbi dergi editörleri kurulunca hazırlanan “Biyomedikal dergilere teslim edilecek metinlerde aranan ortak özelliklerin” 3. baskısındaki (1983) kurallara uygun olarak hazırlanmamış yayın metinlerini kabul etmez. Metinler teslim edilmeden once bu kuralların yayınlandığı British Medical Journal 1988;296:401-5 veya Annuals of Internal Medicine 1988;108:258-65’e bakılmalıdır. 4. Dergiye yazı gönderilmesi sadece internet üzerinden yapılmaktadır. Bunun için resmi web sitesi olan www.agridergisi.com adresindeki ilgili basamaklar takip edilmelidir. 5. Yayınlanması istenen metnin dayandığı çalışma, daha önce başka yerde yayınlanmış veya yayınlanmak üzere teslim edilmiş veya kabul edilmiş olmamalıdır. Özet biçiminde yayınlanmış bir ön bildirinin bitmiş haline yer verilebilir. 6. Dergide yayınlanan yazılar için telif hakkı ödenmez. Bu nedenle başvuru mektubunda telif hakkının dergiye bırakılacağı açıklanmalı ve metnin tüm yazarlarca okunduğunu ve onaylandığını belirten bir ifade bulunmalıdır. 7. Yayımlanmış şekil vb. gereçlerin yerinde basılabilmesi, tanınabilecek kişilerin resimlerinin kullanılabilmesi ve katkılarından dolayı kişilerin adlarının belirtilebilmesi için alınmış izinler posta ile ulaştırılmalıdır. 8. Yazarlar teslim ettikleri her şeyin birer kopyasını saklamalıdır. 9. Teslim edilmiş bir metnin tümünün veya bir bölümünün başka bir yerde yayımlanması söz konusu olursa Editoryal Kurul’a bilgi verilmesi zorunludur. 10. Araştırmalar için, ilgili kurumun bağlı bulunduğu etik komitenin onayının alınmış olması şarttır. Bu durum “gereç ve yöntem” bölümünde belirtilmelidir. 11. Yayımlanan yazıların sorumluluğu yazarlarınındır. 12. Yazarlara tıpkıbasım gönderilmeyecektir. İSTENEN DOSYA TÜRLERİ VE MİNİMUM YAZI TESLİM GEREKLİLİKLERİ Elektronik gönderim sistemiyle yazıların tesliminden önce aşağıdaki formatlama özelliklerine göre ayrı ayrı MS Word (.doc) ve Adobe (.pdf ) dosyaları hazırlanmalıdır. Başvuru mektubu ve başlık sayfası olmayan hiçbir yazı kabul edilmeyecektir. 1. Başvuru mektubu: Her türden yazının gönderimi mutlaka bir başvuru mektubunu içermelidir. Başvuru mektubunda yazar(lar) başlık, yazının türü ve yazının gönderim kategorisi ve gönderilen çalışmanın daha önce bir bilimsel bir toplantıda sunulup sunulmadığını belirtmelidir. Bu başvuru mektubu yazı AGRI Dergisi tarafından incelenme sürecindeyken başka bir yerde yayınlanmayacağı veya yayınlanmak üzere değerlendirilmeyeceğine ilişkin bir açıklama içermelidir. Ayrıca başvuru mektubunun alt kısmında yazışmadan sorumlu yazarın tam adı, adresi, telefon numarası ve e-posta adresi dahil iletişim bilgileri verilmelidir. Başvuru mektubu yazışmadan sorumlu yazar tarafından imzalanmalı, tarayıcıdan geçirilmeli, yazının diğer dosyalarıyla birlikte jpg veya .pdf formatında sunulmalıdır. Başvuru mektubu aşağıdaki gibi düzenlenmelidir: a. Başlık, yazının türü. b. İncelenme sürecindeyken başka bir yerde yayınlanmayacağı veya yayınlanmak üzere değerlendirilmeyeceğine ilişkin bir açıklama. c. Yazışmadan sorumlu yazar(lar)ın tam adı, adresi, telefon numarası ve e-posta adresi dahil iletişim bilgileri. d. Yazışmadan sorumlu yazarın imzası. 2. Başlık sayfası: Gönderilen tüm yazı türleri başlık sayfası dosyasına dahil edilmelidir. Lütfen başlık sayfanızı aşağıdaki unsurları da içeren ayrı bir elektronik dosya şeklinde hazırlayın. a. Yazının başlığı. b. Yazar (Yazarların listesi) lütfen yazarların tam adlarını ve her bir yazar için en fazla iki akademik dereceyi belirtin. Bir kurumda üyelik gibi onursal bağlantıları bu listeye dahil etmeyin. c. Her bir yazarın çalıştığı anabilim dalı veya bölüm, kurum, şehir ve ülke gibi bağlantıları. d. Yazışmalardan sorumlu yazarın (yazarların) tam adı, adresi, telefon numarası ve e-posta adresi gibi iletişim bilgilerini kaydedin. e. Fon tedariki veya başka mali destek hakkında bilgi verilmelidir. f. Çıkar çatışması beyanı: Başlık sayfasının en alt kısmında çıkar çatışması beyanı bulunmalıdır. Lütfen, her bir yazar için ICMJE önerilerine (ICMJE Recommendations) uygun biçimde tüm potansiyel çıkar çatışmaları listesi kaydedilmelidir. Çıkar çatışması yoksa lütfen “Çıkar çatışmaları: Beyan edilmemiştir” ibaresini koyun. 3. Özetler: Özetler sayfasına yazar(lar) sırasıyla özet ve anahtar sözcükler (en az 3 sözcük) yazılmalıdır. Anahtar sözcüklerin Medical Subject Headings (MeSH) (http://www.nlm.nih.gov/mesh/MBrowser.html) standartlarına uygun ve Türkiye Bilim Terimleri’nden (http://www.bilimterimleri.com) seçilmiş olması gerekmektedir. 4. Ana Metin: Gönderilen her yazı türü için bir ana metin dosyası bulunmalıdır. Bu dosya başlık, özetler sayfası, yazınızın ana metni ve tek bir elektronik dosya haline getirilmiş kaynaklar bölümünü içermelidir. Kaynaklar bölümünden sonra tablolar da ayrı sayfalar halinde bu dosyaya konulabilir veya tercihinize göre ayrıca elektronik ortama yüklenebilir. Ana metnin yapısı yazının türüne göre farklılık gösterir. Tablolarla birlikte veya yalnız başına özetler, anahtar sözcükler, ana metin, kaynakları içeren bu birleşik dosya orijinal yazının kimliklerin gizlenmiş olduğu versiyonudur. Yazarların adları, akademik ünvanları, kurumları ve adresleri yazılmaz. Yazının değerlendirme süreci istisna olmak üzere, yazara (yazarlara) ilişkin herhangi bir bilgi içeren yazılar farkına varılır varılmaz rededilecektir. 5. Tablolar: Verileri özetleyen tablolar herhangi bir şablon kullanmaksızın net biçimde formatlandırılmalıdır. Tablolardaki veriler tümüyle metin içinde belirtilmemelidir. a. Tablolar ardışık sırayla numaralandırılmalıdır. b. Metinde her bir tabloya referans verilmiş olunmalıdır. c. Her bir tablonun numarası ve başlığı tablodan önce her sayfanın başına yazılmalıdır. d. Tablolar kaynaklar bölümünden sonra ayrı sayfalar halinde bu dosyaya konulabilir veya tercihinize göre ayrıca elektronik ortama yüklenebilir. Tablolar MS Word (.doc) formatında yüklenmeli ve elektronik dosya buna göre adlandırılmalıdır (Tablolar_xxx_vx.doc). Tablolar pdf, jpeg veya başka bir formatta yüklenmemelidir.

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6. Şekiller: Yazıda şekiller varsa, her yazı türü için her bir Şekil ayrı bir dosya halinde yüklenmelidir. Şekil/görüntülerdeki bilgiler tümüyle tekrar edilmemeli, metinde şekil/görüntüye gönderme yapılmalıdır. a. Teknik gereklilikler i. Şekil alt yazıları kaynaklar bölümünden sonra ayrı bir sayfada belirtilmelidir. ii. Yazı gönderimi sırasında şekillerin hepsi metin dosyasından ayrı bir dosyaya yüklenmeli ve buna göre adlandırılmalıdır (Şekil 1_xxx; Şekil 2_xxx). iii. Şekillerin içine herhangi bir alt yazı veya başlık dahil edilmemelidir. iv. Resimler JPEG, EPS veya TIFF formatında saklanmalıdır. v. Lütfen fotograflar ve şekilleri en azından 300 nokta/inç çözünürlükte gönderin. TIFF veya EPS formatında gönderilen şekilleri son derece kolay işlemekteyiz. b. Etik gereklilikler i. Fotoğrafın sahibi ve/veya fotografı çekilen hasta onam formunu imzamalıdır. İzin alınmadan başka kaynaklardan şekiller kopyalanmamalıdır. 7. Açıklamalar, izinler ve imzalar a. Çıkar Çatışması Formu: Esas ilgilenilen konuya (hastaların iyilik hali veya araştırmanın geçerliliği) ait mesleki bir karar ikincil bir ilgi kaynağından (örn maddi kazanç) etkilenebildiğinde çıkar çatışması söz konusudur. Finansal ilişkiler kolayca saptanabilir. Ancak kişisel ilişkiler veya rekabetler, akademik yarışmalar veya entelektüel inanışlar nedeniyle de çatışmalar oluşabilmektedir. Çatışma gerçek veya potansiyel olabilir. En güvenli süreç Editöre tam olarak beyan etmekten geçer. Çatışmaları açıklamamak bir Erratum (yazım hatası) hatta yazının geri çekilmesine yol açabilmektedir. AGRI Dergisine gönderilen yazıların hepsinde potansiyel veya halen mevcut çıkar çatışmaları olduğu düşünülen tüm ilişkilerin beyan edilmiş olması gerekir. Yazarların hepsinden çıkar çatışmalarını beyan etmeleri istenir. b. Hasta Onam Formu: Hayatta olan tanımlanabilir bir hastaya ait kişisel bilgilerin yayınlanması hasta veya hamisinin açıkça onam vermesini gerektirir. Yazarlardan Kaynaklar menüsündeki Formlar, Şablonlar ve Örnekler sayfasında bulunan standart bir hasta onam formunu kullanmalarını bekleriz. c. Telif Hakkının Nakli Formu: Yazarların tümünden telif hakkının nakli formunu doldurmaları istenir. YAZININ FORMATLANMASI Yazının formatı 2013 Ağustosunda güncellenmiş ICMJE Tıp dergilerinde Bilimsel Çalışmaların Yürütülmesi, Raporlanması, Yayına hazırlanması ve Yayınlanması (ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals) kriterlerine uyumlu olmalıdır. Derginin formatına uymayan yazılar daha fazla gözden geçirilmeden düzelti için yazara iade edilecektir. O halde zaman ve emek kaybından kaçınmak için dergi gönderim kuralları dikkatlice gözden geçirilmelidir. Yazının çatısı WAME kılavuzlarıyla (guidelines of WAME) uyumlu olmalıdır. Genel Format 1. Genel Yazı Stili: Yazı Microsoft WordTM formatında tek sütun halinde yazılmalıdır. Tıbbi jargonlardan kaçınmak için her çaba gösterilmelidir. 2. Tanıtıcı Bilgilerin Gizlendiği İlk Gözden Geçirme: Yazarların adları ve akademik ünvanlar, kurumlar ve adresler gibi tanımlayıcı bilgiler gizlenir. Yazara (yazarlara) ait herhangi bir bilgi içeren yazılar rededilecektir. 3. İlaçlar: İlaçların jenerik adları kullanılmalıdır. Dozlar ve uygulama yolları belirtilmelidir. Ana metinde bir ilaç, ürün, bilgisayar donanım veya yazılımından söz edildiğinde, ürünün adı, üreticisi, firmanın bulunduğu il ve ülke gibi ürün bilgileri aşağıdaki formata göre parentez içinde belirtilmelidir [“Discovery St PET/CT scanner (General Electric, Milwaukee, WI, ABD)]” 4. Kısaltmalar: En gerekli olanlar dışında kısaltma kullanılmasını teşvik etmemekteyiz. Yazar için kolaylık olabilmesine rağmen kısaltmalar genellikle okuyucunun yazıyı kolayca anlamasını engeller. Kısaltmaların tümü ilk kez kullanıldığı anda tanımlanmalı (hem özette, hem de ana metinde) ve kısaltmalar tanımlamadan sonra parentezler içinde gösterilmelidir. Yazarlar başlık ve özette kısaltmalar kullanmaktan kaçınmalı, ana metinde de kullanımları sınırlandırılmalıdır. 5. Ondalık noktalar veya virgüller: Ondalık sayılar tam sayılardan noktalarla ayrılmalıdır. Yazı boyunca ondalık sayılar için virgül kullanmayınız. 6. Kaynaklar: Kaynaklar metin içinde ilk kez yazıldığı sırayla art arda numaralandırılmalıdır (6 yazardan sonra ve ark. kullanın). Özetleri kaynak göstermekten veya kamu kaynaklarında mevcut olmayan esaslı bilgiler sağlamadıkça “kişisel konuşmadan” alıntı yapmayın. Kaynak göstermeye ilişkin örnekler aşağıda gösterilmiştir: o Makale: Süleyman Ozyalçin N, Talu GK, Camlica H, Erdine S. Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain. Eur J Pain 2004;8(6):539-45. o Kitap: Newton ML. Current practice of pain. 1st ed. St. Luis, MO: Mosby; 1990. o Kitaptan bölüm: Turner JA. Coping and chronic pain. In: Bond MR, Charlton JE, Woolf CJ, editors. Pain research and clinical management. Proceedings of the VIth world congress on pain. Amsterdam: Elsevier; 1991. p. 219-27. o Kurslar ve konferanslar (yayınlanmamış): Erdine S. Pain. Course lecture presented at: International Pain Congress, June 7, 2008, İstanbul. YAZI TÜRLERİ VE SPESİFİK FORMATLAMA KILAVUZLARI Makalenin türü, formatlama ve yazının sözcük sayısı dahil kullanılması gereken kılavuzları belirlediğinden yazı gönderiminde ilk adım makalenin türünün tanımlanmasıdır. Araştırma Makalesi: Ağrıda temel bilimler ve klinik araştırmalara ait özgün çalışmalar: Bu makaleler randomize kontrollü çalışmalar, gözleme dayalı çalışmaları (kohort, olgu-kontrollü veya kesitsel), tanısal doğruluk çalışmaları, sistematik derlemeleri ve metaanalizleri, randomize olmayan davranışsal ve halk sağlığı girişimsel çalışmaları, deneysel hayvan çalışmaları veya başka klinik ve deneysel çalışmaları içerebilir. Araştırma makaleleleri aşağıda belirtilen sayfaları, bölümleri ve yukarıda gerekli dosya türleri bölümünde tanımlanmış dosyaları içermelidir: 1. Özetler Sayfası: Hem İngilizce hem de Türkçe özetlerin olması gerekir. Özetler 250 sözcüğü geçmemeli ve aşağıdaki alt başlıklar halinde yapılandırılmalıdır: Amaçlar, Gereç ve Yöntemler (çalışma tasarımıyla birlikte), Bulgular ve Sonuç (olgu kontrollü çalışma, kesitsel çalışma, kohort çalışması, randomize kontrollü çalışma, tanısal doğruluk çalışmaları, metaanalizler, ve sistematik derleme, hayvan deneyleri, randomize olmayan davranışsal ve halk sağlığı girişimsel çalışmaları vs). İstatistiksel analize göre bulgularınızın önemini vurgulayın ideal olarak etki büyüklüğü ve başlıca sonuçlar için güven aralıklarını da bulgulara dahil edin. 2. Ana Metin: Ana metin şu alt başlıklar halinde yapılandırılmalıdır: Giriş, Gereç ve Yöntemler, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekil Alt Yazıları. a. Giriş: Üç paragraflı yapı kullanılmalıdır. Çalışma konusuna ilişkin arka plan bilgileri (1. paragraf ), çalışmanın bağlamı ve çıkarımları (2. paragraf ), çalışmanın varsayımları ve hedefleri (3. paragraf ). Arka plan: Ortamı oluşturan ve sizi konuyu araştırmaya sevk eden koşullar veya tarihsel bağlamı

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tanımlayın. Bağlam: Araştırmanızın niçin önemli olduğunu, potansiyel çıkarımlarının neler olduğunu, ilk paragrafta ortaya atılan konularla ilişkisini, bu spesifik araştırmanın niçin bir sonraki mantıksal adım olduğunu, çalışmanın hedeflerini anlatın ve araştırmanın spesifik amacını veya varsayımını ve birincil sonuç ölçümünüzü açıkça belirtin. b. Gereç ve Yöntemler: Yöntem bölümü özgün araştırma makalelerinin en önemli bölümlerinden biri olup yeterince detaylandırılmalıdır. Araştırma yöntemi, çalışma örneği, uygulanmış analizler, kullanılan ticari istatistik programları, ölçüm ve değerlendirmelerin ayrıntıları (örn: biyokimyasal test cihazları ve kitlerin markası ve modeli) tümüyle açık ve net biçimde belirtilmelidir. Prospektif çalışmalar için yerel etik komite ve diğer onay veren yetkili kurumların adları da Yöntemler bölümünde verilmelidir. Yöntemler bölümü mantıksal ve ardışık alt başlıklar şeklinde düzenlenmelidir. c. Bulgular: Çalışma popülasyonunun demografik özellikleri ve hipotez testinin ana ve ikincil bulguları da kaydedilmelidir. Bu bölümde bulguları yorumlamaktan ve literatür bulgularını tartışmaktan kaçınılmalıdır. Analizlerde edinilmiş olabildiğince çok veriyi bir bütün olarak mümkünse grafikler halinde sunun. Testlerde kullanılan istatistikler temelinde bulguların önemini vurgulayın. Bunun için ideal olarak her bir sonuç için etkinin büyüklüğü ve ilişkili %95 güven aralıklarından yararlanın. d. Tartışma: Çalışmanın birincil ve ikincil sonuçları kısaca sunulmalı, literatürdeki benzer bulgularla karşılaştırılmalıdır. Bu bölümde yoğun arka plan bilgileri vermektem kaçınılmalıdır. Yalnızca sonuçlarınızın yorumlanmasıyla doğrudan ilişkili yayınlanmış makaleleri göz önünde bulundurun ve bunları çalışma bağlamına dahil edin. İstatistiksel anlamı klinik önemden fazla vurgulamayın. Bulgularınızı araştırmanızda açıkça incelemediğiniz toplumlar ve koşullara uyarlamayın. Yöntemler ve Bulgular bölümlerinde formel bir maliyet-etkililik analizi sunmadıysanız maliyet ve ekonomik yarar konularında iddialarda bulunmayın. Bir sonraki aşamanın ne olduğunu spesifik olarak belirtmeden. “Daha fazla araştırma gereklidir” önerisinde bulunmayın. İsterseniz “Geriye baktığımızda …” ile başlayan bir paragraf ilave edip içtenlikle çalışmayı tekrarlama fırsatı verilseydi neleri farklı yapmak isterdiniz konusunu tartışarak başkalarının da deneyimlerinizden bir şeyler öğrenebilmesini sağlayabilirsiniz. e. Limitasyonlar: Çalışmanın limitasyonları tartışma sonunda ayrı bir paragraf içinde “Limitasyonlar” altbaşlığı altında belirtilmelidir. Sonuçlarınızın içsel ve dışsal geçerliliğini tehdit eden etmenler de dahil olmak üzere çalışmanızın limitasyonlarını açıkça tartışın. Mümkünse her bir yanlılığın boyut ve yönünü ve sonuçların yorumlanmasını nasıl etkileyebildiğini inceleyin. f. Sonuç: Çalışmanın bulguları ışığında net bir sonuca varılmalıdır. Çalışma sonuçlarının güncel klinik uygulamalar üzerine potansiyel etkileri tek bir cümleyle belirtilmelidir. Çalışmanın sonuçlarıyla desteklenmeyen çıkarımlarda bulunmaktan kaçınılmalıdır. g. Teşekkür: h. Kaynaklar: Kaynaklar ayrı bir sayfada belirtilmelidir. i. Şekil Alt yazıları: Şekil alt yazıları ayrı bir sayfada ana metin içinde belirtilmeli ve bu sayfa ana metin dosyasının sonuna konmalıdır. j. Tablolar: Ana metin dosyasının sonuna ayrı sayfalar veya ayrı bir dosya şeklinde konmalıdır. k. Şekiller: Ana metin dosyasının içine konmamalı ve yukarıda gerekli dosya türleri bölümünde tanımlandığı gibi ayrı dosyalar halinde yüklenmelidir. l. Etik ve İnceleme Kurulunun Onayı: Yazınız orijinal araştırma ise bir kurumsal inceleme veya etik kurul tarafından onaylandığı veya muaf tutulduğunu doğrulamanız istenecektir. AĞRI Dergisi onaylanmamış veya muaf tutulmamış yazılara daha fazla dikkate almayacaktır. (Yalnızca daha önce IRB (bağımsız etik kurul) onay veya muafiyeti bulunan üçüncü tarafların anonim veri tabanlarının analizleri bu kapsamın dışındadır.) Olgu Raporları: Ağrı pratiğinde nadiren rastlanılan ve eğitsel değeri olan klinik olgular veya komplikasyonların kısa anlatımlarıdır. Mevcut literatürde daha önce belgelenmemiş klinik durumları, klinik belirtileri veya komplikasyonları, bilinen tedavi rejimlerinin raporlanmamış yan veya advers etkileri konusunda ileri araştırmayı tetikleyebilen bilimsel bulgular göz önünde bulundurulacaktır. Olgu raporlarının özetleri 150 sözcüğü geçmemeli, ayrı bir sayfaya yazılmalı ve yapılandırılmamalıdır. Olgu serilerinin ana metni aşağıdaki alt başlıklar altında yapılandırılmalıdır: Giriş, Olgu Sunumları, Tartışma ve Kaynaklar. Kısa Rapor: İlk elde edilen veriler, bulgular veya ileri araştırmaların gerekliliğini gösteren küçük çaplı çalışmaların orijinal raporları. Özetler 250 sözcüğü geçmemeli ve araştırma makalesi şeklinde yapılandırılmalıdır. Limitasyonları, en fazla 6 yazar, 4000 sözcük (kaynaklar, tablolar ve şekil alt yazıları dahil) 15 kaynak, 4 tablo ve/veya şekli içerir. Bu kısıtlamalardan başka, araştırma makalelerin tüm formatları, onay, etik ve yazım kılavuzları kısa raporlar için de geçerlidir. Derleme Makalesi: Güncel ağrı uygulamasına ilişkin ulusal ve uluslararası literatürü gözden geçiren kapsamlı makalelerdir. Genellikle AĞRI Dergisi yalnızca davetli yazarların derleme makalelerini yayınlamaktadır. Diğer yazarlar derleme makalelerini göndermeden önce editörle iletişime geçmelidir. Derleme makalesi en fazla 2 yazarlı olmalı, kaynaklar, tablolar ve şekil altyazıları dahil 4000 sözcüğü geçmemelidir. Kaynakların sayısı sınırlandırılmamıştır. Editöre Mektup: AĞRI Dergisi veya başka dergilerde yayınlanmış makalelere ilişkin düşünceler, yorumlar ve önerileri içerir. Mektuplar en fazla 1.000 sözcük içermelidir. Bu tek yazarlı yazılar için en fazla 5 kaynağın referans gösterilmesine izin verilir. Özet yazılması gerekmemektedir. YAZAR KATKI VE İNSAN VE HAYVAN HAKLARI BİLDİRİMİ Bilimsel katkı ve sorumluluklar, ilgili herhangi bir finansal ya da çıkar çatışması varsa belirtilmelidir. Sorumlu yazar, çalışmanın ve yayının hazırlanmasına katkıda bulunan yazarların adlarını içeren formu imzaladıktan sonra yayıncıya göndermelidir. İnsan deneyleri rapor edilirken, yazarlar prosedürlerin 1975 Helsinki Deklerasyonu-2000, 2008 yılında revize edilen- uyarınca insan deneylerinden (kurumsal ve ulusal) sorumlu etik standartlara uygun olarak olup olmadığı belirtmelidir. Hayvanlar üzerindeki deneyler rapor edilirken, yazarlar laboratuvar hayvanlarının bakımı ve kullanımı için kurumsal ve ulusal rehberi uygulayıp uygulamadığını belirtmelidir. Lütfen makale ile ilgili detayları doldurduğunuz formun (Yazar Katkı ile İnsan ve Hayvan Hakları Bildirimi Formu) çıktısını alın ve formu imzaladıktan sonra faks veya elektronik olarak yayıncıya gönderin. BİLGİLENDİRİLMİŞ ONAM BİLDİRİMİ Bilimsel amaç için gerekli olmadığı sürece, yazılı açıklamalarda, fotoğraflarda ve soy ağacında hastaların isimleri, baş harfleri veya hastane numaralarını içeren tanıtıcı bilgiler yayınlanmamalıdır ve hasta (ailesi ya da vasisi) yayınlanması için yazılı bilgilendirilmiş onam vermelidir. Bu amaç için bilgilendirilmiş onam, tanımlanabilir bir hastaya yayınlanacak makalenin gösterilmesini gerektirir. Yazarlar, yazıma destek sağlayan kişileri belirtmeli ve bu destek için fon kaynağını açıklamalıdır. Tanıtıcı detaylar eğer gerekli değil ise göz ardı edilmelidir. Lütfen makale ile ilgili detayları doldurduğunuz ve hasta veya yakınına formu imzalamalarını rica ettiğiniz formun (Bilgilendirilmiş Onam Bildirimi Formu) çıktısını alın, faks ile veya elektronik olarak yayıncıya gönderin. TELİF HAKLARI VE ÇIKAR ÇATIŞMASI BİLDİRİMİ Yazarlar makalede bahsedilen materyal ile ilgili herhangi bir finansal kuruluş ile herhangi bir çıkar çatışması olmadığını belirtmelidir. Kabul edilen makaleler için, tüm yazarlar tarafından imzalanmış telif hakkı formu gönderilmelidir. Lütfen makale ile ilgili detayları doldurduğunuz formun (Telif Hakkı Devir Formu ve Çıkar Çatışması) çıktısını alın ve formu imzaladıktan sonra faks veya elektronik olarak yayıncıya gönderin. YAYIN ÜCRETİ AĞRI erişme açık bir dergidir. Online olarak derginin web sayfasından yazılara ücretsiz olarak ulaşılmaktadır. Yayınlanan sunumlar için yazarlardan herhangi bir ücret talep edilmez.

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INFORMATION FOR THE AUTHORS

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SCOPE AND PURPOSE This journal, which is published quarterly, is the official publicalion of Turkish Society of Algology, Reviews, details of interentional techniques, original researehes and case reports on the nature, mechanisms and treatment of pain are published. The journal provides a forum for the dissemination of research in the basic and clinical sciences of multidisciplinary interest. INSTRUCTIONS FOR AUTHORS 1. The journal is published in Turkish and in English. 2. Manuscripts which are accepted by Editorial Board can be published. The Editorial Board have the right ro reject or to send the manuscript for review and revise. All manuscripts are subject to editing and, if necessary, will be returned to the authors for responses to outstanding questions or for addition of any missing information. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval. 3. Articles not written according ro the 3rd editian (1983) of “common properties which are wanted in the articles that will be submitted to the Biomedical Journals” which was deternıined by the International Medical Journal Editorial Board, will not be accepted. Before submission it is adviced to look for these guidelines whieh are published in British Medical Journal 1988;296:401-5 or in Annals of Internal Medicine 1988;108:258-65. 4. All paper types are accepted via internet based manuscript processing system (www.journalagent.com/agri). 5. A paper which has not previously been published or being considered for publication elsewhere are accepted for publication. Papers which were published elsewhere previously as an abstract form may be published. 6. No payment for copyright of the article will be done. Therefore the letter accompanying the manuseript should include a statement that copyright of the article is transferred to the Turkish Society of Algology. The final manuscript should have been read and approved by the responsible authors. 7. If illustrations or other small parts of articles or books aIready published elsewhere are used in papers submitted to journal, the written permission of author and publisher corcerned must be included with the manuscript. 8. Authors should keep a copy of their manuscripts. 9. If a part or whole of a submitted manuscript will be published elsewhere, editor of the journal should be informed. 10. For researches, approvement of the institutional local ethics committee or its equivalent should be submitted. 11. All the responsibilities belong to authors. 12. No reprints will be sent to the author. REQUIRED FILETYPES AND MINIMUM SUBMISSION REQUIREMENTS Before submission via electronic submission system, a number of separate MS Word (.doc) and Adobe (.pdf ) files should be prepared with the following formatting properties. No submissions will be accepted without a Cover Letter and a Title Page. 1. Cover Letter: A cover letter file should be included in all types of manuscript submissions. On the cover letter, the author(s) should present the title, manuscript type and manuscript category of the submission, and whether the submitted work had previously been presented in a scientific meeting. The cover letter should contain a statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration by AGRI Journal. In addition, the full name of the corresponding author and his/her contact information including the address, phone number and e-mail address should be provided at the bottom of the cover letter. The cover letter should be signed by corresponding author, scanned and submitted in .jpg or .pdf format with other manuscript files. The order of a cover letter should be as follows: a. Title, manuscript type. b. Statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration. c. Corresponding author(s) full name, contact information including address, phone, and e-mail address. d. Signature of the corresponding author. 2. Title Page: A title page file should be included in all types of manuscript submissions. Please prepare your title page as a separate electronic file, including the following elements: a. Title of the manuscript b. Author(s) list, please list their full names and up to 2 academic degrees per author; do not include honorary affiliations, such as fellow status in an organization. c. Affiliation(s) of each author, including department or division, institution, city, country. d. Corresponding author(s) full name, contact information including address, phone, and e-mail address. e. Funding or other financial support should be acknowledged. f. Conflict of interest statement: A conflict of interest statement should be provided in bottom of the title page. Please list of all potential conflicts of interest for each author, in accordance with ICMJE recommendations. In case of no conflicts of interests, please provide a statement such as: “Conflicts of Interest: None declared”. 3. Abstracts: On the abstracts page, the author(s) should present abstract and keywords (at least three) in this order. Turkish and English keywords should be chosen from Medical Subject Headings (MeSH) (http://www.nlm.nih.gov/mesh/MBrowser.html) and Türkiye Bilimler Terimleri (http://www. bilimterimleri.com). 4. Main Text: A main text file should be included in all types of manuscript submissions. This file should include title, abstracts page, main text of your manuscript, and the references section combined into a single electronic file. Tables can be included in this file as separate pages after References section, or may be uploaded separately as you prefer. Structure of the main text differs between manuscripts types. a. This combined file with the sections of abstracts, keywords, main text, references with/without tables should be a blinded version of the original manuscript. The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Apart from the stage of the manuscript evaluation process, manuscripts submitted with any information pertaining to the author(s) will be rejected as soon as it is noticed. 5. Tables: Tables summarizing the data should be clearly formatted without using any templates. Data presented in the tables should not be included in its entirety in the text. a. Tables must be numbered consecutively. b. Each table must be referred to in the text. c. Number and title of each table should be written at the top of each page before the table. d. Tables can be included in main text file as separate pages after references section, or may be uploaded separately as you prefer. If you prefer a separate file, tables should be uploaded in MS Word (.doc) format and the electronic file should be named accordingly (Tables_xxx_vx.doc). Tables should not be uploaded as pdf, jpeg or else. 6. Figures: If the manuscript includes figures then each figure should be uploaded as a separate file in all types of manuscript submissions. The information contained in the figure/image should not be repeated in its entirety, however reference to the figure/image must be referred in the text. a. Technical requirements

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i. ii. iii. iv. v.

Figure legends should appear on a separate page after the references section. During submission, all figures must be uploaded in a separate file from the text file and should be named accordingly (Figure1_xxx; Figure2_xxx). No legends or titles should be included in the figures. Pictures should be saved in JPEG, EPS or TIFF format. Please submit photographs and figures with a resolution of at least 300 dots per inch. Figures are easiest for us to process if submitted in TIFF or EPS format. b. Ethical requirements i. The owner and/or subject of the photograph must sign the patient consent form. ii. Figures should not be reproduced from other sources without permission 7. Statements, permissions, and signatures: a. Conflict of Interest Form: A conflict of interest exists when professional judgment concerning a primary interest (such as patients’ welfare or validity of research) may be influenced by a secondary interest (such as financial gain). Financial relationships are easily identifiable, but conflicts can also occur because of personal relationships or rivalries, academic competition, or intellectual beliefs. A conflict can be actual or potential, and full disclosure to The Editor is the safest course. Failure to disclose conflicts might lead to publication of an Erratum or even to retraction. All submissions to AGRI must include disclosure of all relationships that could be viewed as presenting a potential or actual conflict of interest. All authors are required to provide a conflict of interest statement and should complete a standard form. b. Patient Consent Form: Publication of any personal information about an identifiable living patient requires the explicit consent of the patient or guardian. We expect authors to use a standard patient consent form. c. Copyright Transfer Form: All authors are required to provide a copyright transfer from with complete a standard form. MANUSCRIPT FORMATTING Manuscript format must be in accordance with the ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals(updated in August 2013). Papers that do not comply with the format of the Journal will be returned to the author for correction without further review. Therefore, to avoid loss of time and work, authors must carefully review the submission rules. Manuscript structure should be complient with the guidelines of WAME. General Format 1. General Style: o The manuscript should be typed in a Microsoft Word™ file, single-column format, Every effort should be made to avoid medical jargon. 2. For the Blind Initial Review: The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected. 3. Drugs: Generic names for drugs should be used. Doses and routes for the drugs should be stated. When a drug, product, hardware, or software mentioned within the main text product information, including the name of the product, producer of the product, city of the company and the country of the company should be provided in parenthesis in the following format: “Discovery St PET/CT scanner (General Electric, Milwaukee, WI, USA)” 4. Abbreviations: We discourage the use of any but the most necessary of abbreviations. They may be a convenience for an author but are generally an impediment to easy comprehension for the reader. All abbreviations in the text must be defined the first time they are used (both in the abstract and the main text), and the abbreviations should be displayed in parentheses after the definition. Authors should avoid abbreviations in the title and abstract and limit their use in the main text. 5. Decimal points or commas: Decimal numbers should be separated from the integers with points. Commas should not be used in decimals throughout the manuscript. 6. References: References should be numbered consecutively in the order in which they are first mentioned in the text (6 authors then “et al”). Avoid referencing abstracts, or citing a “personal communication” unless it provides essential information not available from a public source. Examples of Referencing are as follows: o Article: Süleyman Ozyalçin N, Talu GK, Camlica H, Erdine S. Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain. Eur J Pain 2004;8:539-45. o Book: Newton ML. Current practice of pain. 1st ed. St. Luis, MO: Mosby; 1990. o Book Chapter: Turner JA. Coping and chronic pain. In: Bond MR, Charlton JE, Woolf CJ, editors. Pain research and clinical management. Proceedings of the VIth world congress on pain. Amsterdam: Elsevier; 1991. p. 219-27. o Courses and Lectures (unpublished): Erdine S. Pain. Course lecture presented at: International Pain Congress, June 7, 2008, İstanbul. MANUSCRIPT TYPES AND SPECIFIC FORMATTING GUIDELINES Identification of article type is the first step of manuscript submission because article type dictates the guidelines that should be used, including formatting and word limits of the manuscript. The main categories are outlined below: Research Article: Original studies of basic or clinical investigations in algology. These articles can include randomized controlled trials, observational (cohort, case-control or cross-sectional) studies, destructive studies, diagnostic accuracy studies, systematic reviews and meta-analyses, nonrandomized behavioral and public health intervention trials, experimental animal trials, or any other clinical or experimental studies. Submission of research articles should include below mentioned pages, sections and files as defined above in required filetypes section: 1. Abstracts Page: Both English and Turkish (if relevant) abstracts are required. Abstracts should not exceed 250 words and should be structured with the following subheadings: Objectives, Material and Methods (with design), Results, and Conclusion (case control study, cross sectional study, cohort study, randomized controlled trial, diagnostic accuracy study, meta-analysis and systemic review, animal experimentation, non-randomized study in behavioral sciences and public health, etc.). In your results emphasize the magnitude of findings over test statistics, ideally including the size of effect and its confidence intervals for the principal outcomes. 2. Main Text: The main text should be structured with the following subheadings: Introduction, Material and Methods, Results, Discussion, Acknowledgments, References, Tables, and Figure Legends. a. Introduction: A three-paragraph structure should be used. Background information on study subject (1st paragraph), context and the implications of the study (2nd paragraph) and the hypotheses and the goals of the study (3rd paragraph). Background: Describe the circumstances or historical context that set the stage and led you to investigate the issue. Context: Describe why your investigation is consequential. What are its potential implications? How does it relate to issues raised in the first paragraph? Why is this specific investigation the next logical step? Goals of the study: Clearly state the specific research objective or hypothesis and your primary outcome measure. b. Material and Methods: The method section, is one of the most important sections in original research articles, and should contain sufficient detail. The investigation method, study sample, analyses performed, commercial statistical programs used, details of measurement and evaluation (e.g.: make

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and model of biochemical test devices and kits) should all be clearly stated. The names of local ethics committee or other approving bodies should be provided in Methods section for prospective studies. The Methods section should be organized with logical and sequential subheadings. c. Results: The demographic properties of the study population, the main and secondary results of the hypothesis testing must be provided. Commenting on the results and discussing the literature findings should be avoided in this section. Present as much data as possible at the level of the unit of analysis, graphically if possible. Emphasize the magnitude of findings over test statistics, ideally using size of effect and associated confidence intervals for each outcome. d. Discussion: The main and secondary results of the study should briefly presented and compared with similar findings in the literature. Providing intensive background information should be avoided in this section. Consider only those published articles directly relevant to interpreting your results and placing them in context. Do not stress statistical significance over clinical importance. Avoid extrapolation to populations or conditions that you have not explicitly studied in your investigation. Avoid claims about cost or economic benefit unless a formal cost-effectiveness analysis was presented in the Methods and Results sections. Do not suggest “more research is needed” without stating what the specific next step is. Optionally, you may include a paragraph “In retrospect, . . .” to candidly discuss what you would do differently if given the opportunity to repeat the study, so others can learn from your experience. e. Limitations: The limitations of the study should be mentioned in a separate paragraph subtitled as the “Limitations” in the end of the discussion. Explicitly discuss the limitations of your study, including threats to the internal and external validity of your results. When possible, examine the magnitude and direction of each bias and how it might affect the interpretation of results. f. Conclusion: A clear conclusion should be made in the light of the results of the study. The potential effects of the results of the study on the current clinical applications should be stated in a single sentence. Inferences that are not supported by the study results should be avoided. g. Acknowledgments: h. References: References section should be in a separate page. i. Figure Legends: Figure legends should be included in the main text in a separate page and this page should be the at the end of the main text file. j. Tables: At the end of the main text file as separate pages or as a separate file. k. Figures: Should not be included in the main text file and should be uploaded as separate files as with the properties describes above in required filetypes section: l. Ethics or Review Board Approval: If your manuscript involves original research, you will be asked to verify approval or exemption by an institutional review or ethics board. AGRI Journal will be unable to further consider manuscripts without approval or formal exemption. (The only exceptions are for analyses of third party anonymized databases which already have pre-existing IRB approval or exemption.) Case Reports: Brief descriptions of clinical cases or the complications that are seldom encountered in algology practice and have an educational value. Consideration will be given to articles presenting clinical conditions, clinical manifestations or complications previously undocumented in the existing literature and unreported side of adverse effects of the known treatment regimens or scientific findings that may trigger further research on the topic. Abstracts of case reports should mainly include information about the case, should not exceed 150 words, must be on a separate page and should be unstructured. The main text of Case Series should be structured with the following subheadings: Introduction, Case Presentations, Discussion and References. Brief Report: Original reports of preliminary data and findings or studies with small numbers demonstrating the need for further investigation. Abstracts should not exceed 250 words and structured as research articles. Limitations include: maximum 6 authors, 4000 words (including references, tables, and figure legends), 15 references, 4 tables and/or figures. Besides these constraints, all the formatting, approval, ethics and writing guidelines of research articles also applies to brief reports. Review Article: Comprehensive articles reviewing national and international literature related to current algology practice. Generally AGRI Journal publishes only invited review articles. Other authors should contact the editor prior to submission of review articles. Maximum 2 authors, 4000 words (including references, tables, and figure legends). There is no limit to the number of references. Letter to the Editor: Opinions, comments and suggestions made concerning articles published in AGRI Journal or other journals. Letters should contain a maximum of 1,000 words and 5 references are allowed for these single author submissions. No abstract is required. AUTHOR CONTRIBUTION & STATEMENT OF HUMAN AND ANIMAL RIGHTS Scientific contribution and responsibilities, any financial or other conflict of interest should be mentioned. Corresponding author should include the names of the authors who contributed to the preparation of the study and the manuscript and send to publisher after signing the form. When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008. When reporting experiments on animals, authors should be asked to indicate whether the institutional and national guide for the care and use of laboratory animals was followed. Please print out the form (Author Contribution & Statement of Human and Animal Rights Form) fill in the details about the article and sent to publisher by fax or electronic submitting system after signing the form. STATEMENT OF INFORMED CONSENT Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients’ names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Please print out the form (Statement of Informed Consent Form), fill in the details about the article, ask the patient or next of kin to sign the form, and sent to publisher by fax or electronic submitting system after signing the form. COPYRIGHT & STATEMENT OF CONFLICT OF INTEREST Authors should also state that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Transfer of copyright form which is signed by all authors must be sent for accepted manuscripts. Please print out the form (Conflict of Interest & Transfer of copyright form), fill in the details about the article and sent to publisher by fax or electronic submitting system after signing the form. PUBLISHING FEE AGRI is an open access journal. Manuscripts can be reached from the web page of journal without any fees. No additional fee is required from the authors for accepted manuscripts.

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a l i k

Agri 2017;29(2):51–54

doi: 10.5505/agri.2017.87369

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INVITED REVIEW

Pain in women Kadınlarda ağrı Inna BELFER Summary Men and women are different in response to experimental painful stimulation, in pain attitude such as reporting pain and pain coping behavior, in symptoms and signs of painful disorders and in response to pain treatment. Both acute and chronic pain conditions have diverse prevalence among the sexes. Overall, women have more than twice higher prevalence in painful disorders compared to men. Here I review putative mechanisms underlying sex differences in pain, including genetic factors that have sex-specific or sex-biased effects controlling pain and analgesia. Keywords: Female pain; pain; sex differences; sex-specific gene effects.

Özet Erkekler ve kadınların deneysel ağrılı uyarılara yanıt, ağrıyı bildirme, ağrıyla başa çıkma davranışları ağrılı rahatsızlıkların semptom ve belirtileri ve ağrı tedavisine yanıt gibi ağrıya karşı tutumları farklıdır. Hem akut hem de kronik ağrılı durumların erkek ve kadınlardaki prevalansları farklılık gösterir. Genelde erkeklere göre kadınlarda ağrılı durumların prevalansı daha yüksektir. Burada, ağrının kontrolü ve yitiminde cinsiyete özgü veya cinsiyet eğilimli etkiler gösteren genetik faktörler de dahil olmak üzere ağrıda cinsiyet farklılıklarının altında yattığı varsayılan mekanizmalar gözden geçirildi. Anahtar sözcükler: Dişi cinsiyette ağrı; ağrı; cinsiyet farklılıkları; cinsiyete özgü genetik etkiler.

When it comes to pain, the clinicians know that men and women are not the same. There are conspicuous sex differences in response to experimental painful stimulation, in pain attitude such as reporting pain and pain coping behaviors, in symptoms and signs of painful disorders and in response to pain treatment. Furthermore, the prevalence rates of both acute and chronic pain conditions differ between men and women (see Table 1). Overall, women have more than twice higher prevalence in painful disorders compared to men. Finally, male and female subjects suffer differently from pain after identical surgical procedures. A prospective trial in Austria measuring pain intensity 24 hours after surgery didn’t find overall sex influence. However, when stratified for surgical procedures, the results showed that men were prone to experience a greater number of moderate pain after major vascular and orthopaedic surgery while females reported

higher pain ratings after diagnostic procedures (e.g. biopsies).[1] This means that the same risk factors contribute contrarily to male and female pain. A sex difference in pain is an understudied topic: until the 1990s, most scientific research was conducted in the middle-aged white male subjects.[2] In recent years there is raising evidence on disparities in pain perception between the sexes suggesting unique pain mechanisms and targeted analgesic strategies for women and men. Generally, women demonstrate lower pain thresholds and higher willingness to acknowledge pain that may serve as protective mechanism. Indeed, what women are doing is recognizing a problem earlier, which gives them more of a means to deal with it; so with greater vulnerability comes greater strength.

Adjunct Professor of Human Genetics and Medicine, University of Pittsburgh, Pittsburgh, PA, USA Correspondence: Dr. Inna Belfer. Office of Research on Women’s Health, DHHS/NIH/OD/DPCPSI, Democracy II, Suite 400, 6707 Democracy Blvd, Bethesda, MD 20892-5484, USA. Tel: +1 301-435-1573 e-mail: inna.belfer@nih.gov © 2017 Turkish Society of Algology

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A RI PAIN Table 1. Sex prevalence of common pain disorders Painful condition

Sex ratio

Migraine headache with aura F>M Chronic tension headache F>M Post-dural puncture headache F>M Hemicrania continua F>M Cervicogenic headache F>M Temporomandibular joint disorder F>M Fibromyalgia F>M Multiple sclerosis F>M Rheumatoid arthritis F>M Atypical odontalgia F>M Burning tongue F>M Carotidynia F>M Chronic paroxysmal hemicrania F>M Temporal arteritis F>M Carpal tunnel syndrome F>M Raynaud’s disease F>M Chilblains F>M Causalgia F>M Reflex sympathetic dystrophy F>M Hemicrania continua F>M Chronic venous insufficiency F>M Esophagitis F>M Reflux esophagitis with peptic ulcer F>M Slipping rib syndrome F>M Twelfth rib syndrome F>M Gallbladder disease F>M Interstitial cystitis F>M Acute intermittent porphyria F>M Proctalgia fugax F>M

Painful condition

Sex ratio

Chronic constipation F>M Pyriformis syndrome F>M Migraine without aura M>F Cluster headache M>F Post-traumatic headache M>F Abdominal migraine M>F Lateral femoral cutaneous neuropathy M>F Post-herpetic neuralgia M>F Hemophilic arthropathy M>F Ankylosing spondylitis M>F Brachial plexus avulsion M>F Pancreatic disease M>F Duodenal ulcer M>F Familial Mediterranean fever F=M Hereditary coproporphyria F=M Acute herpes zoster F=M Burns F=M Esophageal motility disorders F=M Chronic gastric ulcer F=M Chron’s disease F=M Neuralgia of nervus intermedius F=M Painful ophthalmoplegia F=M Maxillary sinusitis F=M Toothache due to dentinoenamel defects F=M Toothache due to pulpitis F=M Cracked tooth syndrome F=M Dry socket F=M Vagus nerve neuralgia F=M Acute tension headach F=M Clustertic syndrome F=M

F: Female; M: Male.

Female vulnerability to pain may manifest in many areas. For somatic stimuli, females have lower sensitivity and greater ability to discriminate, higher pain ratings, and less tolerance of noxious stimuli than males.[3] For endogenous pains, women report more multiple pains in more body regions than men. Majority of chronic “functional” pain conditions such as migraine, irritable bowel syndrome, tempomandibular joint disorder and fibromyalgia predominately affect women. This vulnerability can be explained by several putative mechanisms. First of all, vaginal canal provides an additional route for internal trauma and invasion by pathological agents increasing the 52

risk for developing hyperalgesia in multiple body regions. There are different effects of chronobiology on pain in women and men: some of them are common such as puberty and senescence or a time of day, and some are female-specific such as influences of menstrual cycle, pregnancy and menopausal changes. This is in line with reports on female prevalence in many common pain conditions increasing across the pubertal period. Sex differences in temporal patterns are likely to give rise to sex differences in how pain is “learned” and stimuli are interpreted increasing variability and wider range of pains without obvious peripheral pathology. There are sex difAPRIL 2017


Pain in women

ferences in glial cells function since glia interacts with estrogen and progesterone[4] and in serotonin /dopamine system with more prominent serotonic influences on the processing of information in males than females.[5] Finally, there are different hormonal effects on pain. A fascinating work in transsexuals of Aloisi et al. showed that gonadal hormones affect the occurrence and incidence of pain. Transsexuals who receive cross-sex hormones to develop and maintain somatic characteristics of the opposite sex may get more prone or protected depending on the hormone treatment: one-third of the male to female transsexuals developed chronic pain concomitantly with estrogen/anti-androgen treatment and showed increased pain sensitivity following hormonal therapy schedule, while about half of the female to male transsexuals treated with testosterone reported a significant improvement of the chronic pain (e.g., headache) already present before the start of treatment and had improved pain sensitivity profiles following hormonal regime.[6] Interestingly, sex differences in pain may have genetic background. A growing body of evidence demonstrates that genes controlling severe acute or more chronic human pain have sex-specific effects. For example, gene encoding Catechol-O-methyltransferase (COMT), an enzyme that inactivates biologically-active catechols, including neurotransmitters dopamine, noradrenaline and adrenaline, modulating pain, has sexually dimorphic effects.[7] Functional polymorphic alleles in this gene affect female pain much stronger than male pain, both in animals and humans. As a result, women carrying those alleles are much more sensitive to pain compared to men and are prone to develop chronic pain conditions. A gene encoding GTP cyclohydrolase, a rate- limiting enzyme for tetrahydrobiopterin synthesis, has functional alleles protective for neuropathic pain[8] in men but predisposing women to sickle cell pain crises.[9] A gene encoding Mu-opioid receptor, a main binding site for endogenous and exogenous opioids, has a functional variant with minor allele associated with greater pressure pain thresholds and less cortical response to experimental pain in men,[10] but higher pain after cesarean section in women.[11] Moreover, a recent study in patients with low back pain and sciatica after lumbar disc herniation found that this same allele increased twice the pain intensity in women APRIL 2017

compared to men.[12] Thus, human pain genes may have sex-biased effects affecting both sexes but to different degrees; sex-specific effects affecting only one but not another sex; and sex-antagonistic effects affecting both sexes but in opposite directions. Genetic control of sex differences in pain suggests unique molecular pain pathways in men and women. Identification of these pathways may inform clinical management of pain starting from sex-specific pain assessment to personalized pain management through sex-specific analgesia. With sex-specific pain risk signatures, the clinicians will be able to avoid expensive and/or risky treatments for those who will not likely benefit from them or recover anyway. With sex-specific analgesic response signatures, the clinicians will make informative decision on the selection of the optimal drug and dose and predict side effects of selected therapies. Finally, the recent advances in genetics and pharmacogenetics of human pain, we can expect the development of novel sex-specific pain medications and pain genetic testing specific for men and women. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

References 1. The influence of sexes on postoperative pain. Euroanaesthesia 2014. http://www.esahq.org/congresses/pasteuroanaesthesia/euroanaesthesia-2014/enewsletters/ enewsletter-day4/study-of-over-10000-patients-suggests-men-experience-more-pain-after-major-surgery (access date: 6 April2017). 2. Greenspan JD, Craft RM, LeResche L, Arendt-Nielsen L, Berkley KJ, Fillingim RB, et al. Studying sex and gender differences in pain and analgesia: a consensus report. Pain 2007132 Suppl 1:S26–45. 3. Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of clinical and experimental findings. Br J Anaesth 2013;111(1):52–8. 4. Watkins LR, Hutchinson MR, Johnston IN, Maier SF. Glia: novel counter-regulators of opioid analgesia. Trends Neurosci 2005;28(12):661–9. 5. McEwen BS, Alves SE, Bulloch K, Weiland NG. Clinically relevant basic science studies of gender differences and sex hormone effects. Psychopharmacol Bull 1998;34(3):251–9. 6. Aloisi AM, Bachiocco V, Costantino A, Stefani R, Ceccarelli I, Bertaccini A, et al. Cross-sex hormone administration changes pain in transsexual women and men. Pain 2007;132 Suppl 1:S60–7.

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A RI PAIN 7. Belfer I, Segall SK, Lariviere WR, Smith SB, Dai F, Slade GD, et al. Pain modality- and sex-specific effects of COMT genetic functional variants. Pain 2013;154(8):1368–76. 8. Tegeder I, Costigan M, Griffin RS, Abele A, Belfer I, Schmidt H, et al. GTP cyclohydrolase and tetrahydrobiopterin regulate pain sensitivity and persistence. Nat Med 2006;12(11):1269–77. 9. Belfer I, Youngblood V, Darbari DS, Wang Z, Diaw L, Freeman L, et al. A GCH1 haplotype confers sex-specific susceptibility to pain crises and altered endothelial function in adults with sickle cell anemia. Am J Hematol 2014;89(2):187–93. 10. Fillingim RB, Kaplan L, Staud R, Ness TJ, Glover TL, Campbell

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CM, et al. The A118G single nucleotide polymorphism of the mu-opioid receptor gene (OPRM1) is associated with pressure pain sensitivity in humans. J Pain 2005;6(3):159– 67. 11. Tan EC, Sia AT. Effect of OPRM variant on labor analgesia and post-cesarean delivery analgesia. Int J Obstet Anesth 2010;19(4):458–9; author reply 459-60. 12. Olsen MB, Jacobsen LM, Schistad EI, Pedersen LM, Rygh LJ, Røe C, et al. Pain intensity the first year after lumbar disc herniation is associated with the A118G polymorphism in the opioid receptor mu 1 gene: evidence of a sex and genotype interaction. J Neurosci 2012;32(29):9831–4.

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Agri 2017;29(2):55–63

doi: 10.5505/agri.2017.89106

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ORIGINAL ARTICLE

Coping with the pain of elderly pain patients: Nursing approach Geriatrik ağrı hastalarının ağrıyla başa çıkma durumları: Hemşirelik yaklaşımı Burcu BABADAĞ,1 Güler BALCI ALPARSLAN,1 Sacit GÜLEÇ2 Summary Objectives: This study was designed to examine methods used by elderly patients to cope with pain and serve as a guide for nurses. Methods: This descriptive survey was carried out with geriatric patients (n=100) aged 60 years or more in inpatient Algology Unit of a university hospital between November 28, 2014 and January 28, 2015. Data were collected using descriptive characteristics questionnaire prepared based on review of the literature and via one-on-one interviews using Pain Coping Questionnaire (PCQ). Data were evaluated using descriptive statistical methods, Independent sample t-test, one-way analysis of variance test, and Pearson correlation coefficient. Results: Duration of pain experienced by the patients ranged from 1 month to 40 years, with mean duration of 63.57±82.65 months. Mean subscale scores of PCQ were: self-management, 19.22±6.54; helplessness, 13.45±3.86; conscious coping efforts, 11.90±3.97; and medical remedies, 12.62±3.98. Score of the patients who reported that they could manage their pain on their own (p<0.05), and of those who relied on medical remedies, believing that pain control is in the hands of nurses (p<0.05), were significantly higher. Conclusion: Means of coping with pain vary in geriatric patients and it is recommended that these differences be taken into account in nursing interventions. Keywords: Coping with pain; geriatric pain; nursing care; pain.

Özet Amaç: Bu tanımlayıcı çalışma geriatrik ağrı hastalarının ağrıyla başa çıkma yollarını belirlemek amacıyla yapıldı. Gereç ve Yöntem: Tanımlayıcı tipte yapılan araştırma, bir üniversite hastanesinin Algoloji Servisi’nde yatan, 60 yaş ve üzerinde olan 28 Kasım 2014–28 Ocak 2015 tarihleri arasında 100 hastayla yürütüldü. Veriler araştırmacılar tarafından ilgili literatür taranarak hazırlanan Tanımlayıcı Özellikler Veri Formu ve Ağrıyla Başa Çıkma Ölçeği kullanılarak yüz yüze görüşme yöntemiyle toplandı. Verilerin değerlendirilmesinde tanımlayıcı istatistiksel metodlar, t testi, One-way Anova testi kullanıldı. Bulgular: Hastaların ağrı yaşama süresi 1 ay ile 40 yıl arasında değişmekte olup, ortalama ağrı yaşama süresi 63.57±82.65 aydı. Hastaların ağrıyla başa çıkma ölçek alt boyutundan aldıkları puan ortalamaları; kendi kendine başa çıkma 19.22±6.54, çaresizlik 13.45±3.86, bilinçli bilişsel girişimler 11.90±3.97 ve tıbbi çare arama 12.62±3.98 idi. Ağrı kontrolünün kendisinde olduğu inancına sahip hastaların kendi kendine başa çıkma ölçek puanları (p<0.05), ağrı kontrolünün hemşirede olduğuna inancına sahip olanların tıbbi çare arama ölçek puanları (p<0.05) anlamlı düzeyde yüksek bulundu. Sonuç: Sonuç olarak, geriatrik bireyin ağrıyla başa çıkma yolları değişiklik göstermekte ve uygulanacak hemşirelik girişimlerinde bu farklılıkların göz önüne alınması önerilmektedir. Anahtar sözcükler: Ağrıyla başa çıkma; yaşlı ağrı; hemşirelik bakımı; ağrı.

Introduction The increase in the elderly population brings about various health problems. Pain is a major problem seen along with chronic diseases which have a high incidence in geriatric population. Particularly elder individuals experience the pain in a chronic manner

and their methods for coping with the pain may vary. “Coping” is the resistance of a person against the events or factors that create stress and the cognitive, emotional and behavioral reactions to endure against these. The coping attitudes against these cases may vary according to several factors including age, gen-

Department of Nursing, Eskişehir Osmangazi University Faculty of Health Science, Eskişehir, Turkey Department of Anesthesiology and Reanimation, Head of Algology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey

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Submitted (Başvuru tarihi) 01.08.2016 Accepted after revision (Düzeltme sonrası kabul tarihi) 17.02.2017 Available online date (Online yayımlanma tarihi) 20.02.2017

Correspondence: Dr. Burcu Babadağ. Eskişehir Osmangazi Üniversitesi, Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü, Meşelik Kampüsü, Eskişehir, Turkey. Phone: +90 - 222 - 239 37 50 e-mail: burcubabadag1@gmail.com © 2017 Turkish Society of Algology

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55


A RI PAIN der, culture and disease and are unique for each individual.[1,2] The concept of coping becomes more important particularly in the elderly. Coping with the pain also refers to the management of pain. Besides the pharmacological pain management methods, behavioral and cognitive therapies can also be used to manage the pain.[3,4] Many elderly individuals are also inclined to non-pharmacological methods of pain management. Nurses have an important role in informing and guiding the elderly about such appropriate methods as exercise, relaxation, acupuncture, music therapy and spiritual interventions.[5] Several previous studies have reported the differences in the methods for coping with the pain among patients with chronic pain.[6] There are also some studies demonstrating the coping status of the elderly individuals with the pain. Among the commonly used methods for coping with pain are analgesic use, cognitive methods, (spiritual activities, praying, worship, etc.), activity limitation, resting and distraction.[7,8] On the other hand, Benyon et al. (2013) have suggested that catastrophizing the pain is a predisposing factor for the increased pain severity and inability.[9] Both pharmacological and non-pharmacological methods should be used for the management of pain in the elderly. Nonpharmacological methods include distraction (for example; watching TV or talking on the phone), position changes, behavioral therapy, music therapy and relaxation.[5] Nurses have several roles and functions such as giving education, counseling, guiding, comforting, and being an administrator, caregiver and rehabilitative. Nurses should guide the elderly patients who experience pain by using these roles. [10,11] In other several studies, it has been found that nurses are effective in the pain management.[5,12,13] In conclusion, nurses should know the methods of elder individuals for coping with the pain in order to help them to cope with the pain. Several studies have reported that geriatric individuals have difficulties in coping with the pain.[8,14] Identification of these difficulties and knowing the coping methods used by elder individuals are of much importance in order for nurses to manage the pain much better. Therefore, this study was planned as a guide for nurses in order to define the coping methods of elderly pain patients. 56

Materials and Methods This is a descriptive study carried out to determine the coping methods of elderly pain patients. The study was conducted on 100 inpatients in the Algology Clinic of a University Hospital between November 28, 2014 and January 28, 2015. The patients were 60 years or over, having non-malignant pain, no psychiatric disorder or no loss of consciousness due to a drug or disease, no communication problem, agreeing to participate in the study, and having at least two hours past after any intervention.[15] The data were collected by one-on-one interview method and after obtaining informed consent. The study was approved by the Eskişehir Osmangazi University Faculty of Medicine Clinical Research Ethics Board (Number: 80558721/311, Decision No: 01) and by obtaining the informed consent form from the patients and the consent for using the scales. Data collection Measures The Descriptive Characteristics Data Form prepared by the researchers by scanning the literature and the Pain Coping Questionnaire[6,16–18] were used for collecting the data. Descriptive Characteristics Data Form The form was prepared by the researchers by scanning the available literature.[6,16,17] It consists of 11 items about sociodemographic characteristics including age, gender, marital status, residence, educational status, employment status and medical diagnosis and 14 items about the pain including pain severity and the site of pain. Pain Coping Questionnaire The Pain Coping Questionnaire (PCQ) was developed in 1992 by Kleinke in order to determine the pain-related emotions and behaviors.[16,18] The reliability and validity studies were carried out in 1996 by Karaca et al. and the questionnaire was adapted then into Turkish.[6] This questionnaire evaluates the methods to cope with organic and psychogenic pain in patients with chronic pain. It consists of 4 subscales: Self-management, Helplessness, Conscious Coping Attempts and Medical Remedies. There is no cut-off value for the scores. The minimum possible score is “0” for all subscales and the maximum possible score is “36” for Self-management, “24” for APRIL 2017


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Helplessness and Conscious Coping Attempts, and “27” for Medical Remedies subscales. The reliability studies for the questionnaire yielded an internal consistency of 0.75 determined by cronbach alpha coefficient.[6] Statistical Methods The data were analyzed by using IBM SPSS Statistics 21.0 package program. Descriptive statistical methods (mean, standard deviation, numbers and percentage) were used for the analysis of the data. Independent sample t test, One way Anova test and Pearson correlation test were used for normally distributed data. p<0.05 was considered as significant.

Results Sociodemographic Characteristics The age of the participants ranged from 60 to 87 years with a mean age of 67.26±6.43 years. Of the patients, 74.0% were female, 77.0% were married and 72.0% were primary school graduates. On the other hand, 40.0% of the patients reported their income level to meet their expenses, 93.0% was unemployed and all (100%) had social insurance. Of the participants, 91.0% were living at home with the spouse and children and 98.0% reported that they get social support from their family outside the hospital. On the other hand, 88.0% had a diagnosis of musculoskeletal disease and 78.0% were using nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain management (Table 1). Pain-Related Characteristics Of the geriatric patients, 93.0% had a pain resulting from other causes with 97.8% of these patients reporting that they have been treated for this complaint. Moreover, 81.0% reported that there are individuals close to them experiencing pain. The pain was in the back or lumbar region in 36.0% and was severe in 39.0% of the patients. The duration of the pain ranged from 1 month to 40 years with a mean duration of 68.57±82.65 months. The most common treatment program was radiofrequency (51.0%). The duration of the treatment ranged from 1 month to 15 years with a mean duration of 27.49±33.30 months. Of the patients, 76.0% were satisfied from the treatment. 74.0% of the patients believed that the pain is controlled by the God and 88.0% of the patients reported the other person helping the pain manageAPRIL 2017

Table 1. Sociodemographic characteristics (n=100) Gender Female Male Marital status Married Unmarried Educational status Illiterate Only-literate Primary school graduate Secondary school graduate Highschool or over Income level Income is lower than expenses Income meets the expenses Income is higher than expenses Employment status Employedb Unemployedc Households Living alone Spouse/children Social support outside the hospital Family Relatives, friends, neighbors Medical diagnosis Musculoskeletal diseased Neuralgiare Migraine Drugs in use for pain management NSAIDs Opioids Adjuvant Drugsf

n

%a

74 26

74.0 26.0

77 23

77.0 23.0

9 4 72 10 5

9.0 4.0 72.0 10.0 5.0

31 40 29

31.0 40.0 29.0

7 7.0 93 93.0 9 91

9.0 91.0

98 2

98.0 2.0

88 88.0 8 8.0 4 4.0 78 78.0 8 8.0 50 50.0

Percent of the sum of the column; bWorker, cervant, shopkeeper, farmer; cHousewife, retired, unemployed; dLumbar discopathy, cervical discopathy, arm-shoulder pain, frozen shoulder, tarsal tunnel syndrome, carpal tunnel syndrome, fibromyalgia, gonarthrosis, ankylosing spondilitis, post-laminectomy syndrome; eTrigeminal neuralgia, atypical fascial pain, pudental neuralgia, neuropathic pain; f Antidepressants, anxiolytics, anticonvulsants, myorelaxing agents, immunosuppresives. a

ment as the physician. Of the patients, 95.0% reported that they have knowledge about the pain with the most common source is neighbors and friends (44.6%). However, 82.1% reported that this information is inadequate (Table 2). 57


A RI PAIN Table 2. Pain-related characteristics (n=100)

Table 3. Subscores on the Pain Coping Questionnaire

PCQ

Min. Max. Mean±SD

Self-management Helplessness Conscious coping attempts Medical remedies

3.00 35.00 19.22±.65 4.00 22.00 13.45±.38 3.00 23.00 11.90±.39 3.00 23.00 12.62±.39

n %

Site of pain Back/lumbar region 36 36.0 Head-neck 11 11.0 Arm-shoulder 20 20.0 Leg-knee 29 29.0 a Other 4 4.0 Pain severity Mild 5 5.0 Moderate 15 15.0 Severe 39 39.0 Very severe 31 31.0 Intolerable 10 10.0 b Pain control is In the individual 20 20.0 In the nurse 4 4.0 In the physician 45 45.0 In God 74 74.0 Other persons helping the pain managementb Physician 88 88.0 Family 48 48.0 Nurse 15 15.0 Friends-neighbors 2 2.0 Information about the pain Yes 95 95.0 No 5 5.0 Source of informationb n=95 Neighbors-friends 47 44.6 Media 46 43.7 Physician 31 29.4 Nurse 14 13.3 Other healthcare personnel 3 2.8 Adequacy of the information obtainedc n=95 Yes 17 17.9 No 78 82.1 Chest, hand-wrist feet; bMore than one choice was marked; cOnly the patients having information about the pain were included (n=95).

a

Pain Coping Questionnaire Scores The mean scores on the subdimensions of PCQ were 19.22±6.54 for self-management, 13.45±3.86 for helplessness, 11.90±3.97 for conscious coping attempts and 12.62±3.98 for medical remedies (Table 3). The Correlation Between Subscores of PCQ Self-management subscore was strongly positively 58

Min.: Minimum; Max.: Maximum; SD: Standard deviation.

correlated with the conscious coping attempts subscore (p<0.001, r=.798) and weakly negatively correlated with the helplessness subscore (p<0.001, r=-.432). On the other hand, helplessness subscore was strongly positively correlated with the medical remedies subscore (p<0.01, r=.340). There was a weak positive correlation between conscious coping attempts and medical remedies subscores (p<0.05, r=.278) (Table 4). Comparison of the Sociodemographic Characteristics with PCQ subscores Subscores for medical remedies was significantly higher in female patients compared to male patients (p<0.05); however, there was no other significant difference between the PCQ subscores and sociodemographic characteristics. The subscores for self-management were significantly higher in patients using NSAIDs compared to those not using and were also significantly higher in patients not using opioids compared to those using (p<0.05). There was a significant difference between the diagnosis of the patients and self-management (p<0.05), conscious coping attempts (p<0.01) and medical remedies (p<0.01) subscores. Multiple comparisons showed that the difference is more obvious in the neuralgia and musculoskeletal disease patient groups. Self-management, conscious coping attempts and medical remedies subscores were significantly lower in patients with neuralgia compared to those with musculoskeletal disease (p<0.01 for each). Comparison of Pain-Related Variables with PCQ Subscores There was a significant difference between the site of pain and self-management subscore (p<0.05), conscious coping attempts subscore (p<0.05) and medical remedies subscore (p<0.01). When the difference between the sites of pain is analyzed APRIL 2017


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Table 4. Correlation between the PCQ subscores Variables Self-management r p Helplessness r p Conscious coping attempts r p Medical remedies r p

Self-management

Helplessness

Conscious coping attempts

Medical remedies

-.432*** <0.001

.798*** <0.001

-.185 .066

.004 .965

.340** .001

.278* .005

*p<0.05; **p<0.01; ***p<0.001.

in terms of multiple comparison, there have been found a significant difference in that the subscores of self-management and medical remedies are significantly lower (p<0.05 for each) while conscious coping attempts subscore is significantly higher for patients having pain in the head-neck regions compared to those having in the back-lumbar region (Table 5). There was a significant difference between the pain severity and self-management subscore (p<0.05) and heplessness subscore (p<0.001). According to the multiple comparisons, the self-management subscore was significantly higher in patients having moderate pain compared to those having mild, very severe and intolerable pain (p<0.05). The helplessness subscore was found to be significantly higher in patients having severe and very severe pain compared to those having mild and moderate pain (p<0.05) (Table 5). The self-management subscore was significantly lower in patients who had previously received a treatment for pain and medical remedies score was significantly higher in patients satisfied from the treatment (p<0.05). The self-management subscore was significantly higher in patients believing that the control of pain is in the hands of himself/herself (p<0.05) and medical remedies subscore was significantly higher in patients believing that the control of pain is in the nurse (p<0.01). On the other hand, conscious coping attempts subscore was significantly higher in geriatric patients who had received information about pain compared to those who had not (p<0.05) (Table 5). APRIL 2017

Discussion Pain Coping Questionnaire Scores According to the Pain Coping Questionnaire subscores given in Table 3, the self-management subscore is associated with getting away from negative thoughts, exercises, communication skills, relaxation programs and pain-related education.[19] The helplessness subscore is associated with selective abstraction, over-generalizing and cognitive distortions related to the personalization.[18] It is defined as the inability to cope with the pain effectively. Catastrophizing is defined as the feeling of having a disaster.[19] The subscore of conscious coping attempts focuses on the cognitive methods and are associated with cognitive coping methods with the pain such as distraction, re-interpretation of the pain and daydreaming.[6] The subscore of medical remedies is associated with the coping method with the pain by using medical therapy.[18] In our study carried out on elder individuals, conscious coping attempts subscore increased and helplessness subscore decreased with the increasing self-management subscore (Table 4). Previous studies have concluded that individuals with long-term pain and no pain control feel themselves helpless and have problems in coping with the pain.[12,20,21] Lapierre et al. (2015) Most of the patients with chronic disease want to die with 57.9% having arthritis or rheumatoid disease. The authors concluded that especially the patients with painful chronic disease (for 59


A RI PAIN Table 5. Comparison of pain-related variables with pain coping subscores Subscales Site of pain* Back-lumbar Head-neck Arm-shoulder Leg-knee Other p/F Pain severity* Mild Moderate Severe Very severe Intolerable p/F Previous treatment for pain** Yes No p/F Satisfaction from the treatment** Yes No p/F Control of the pain is in the hands of himself/herself** Yes No p/F Control of the pain is in the nurse** Yes No p/F Having information about pain** Yes No p/F

Pain Coping Questionnaire

Self-management

Helplessness

Mean±SD

Mean±SD

Conscious coping attempts Medical remedies

19.05±6.65 14.36±3.88 14.63±6.56 14.09±3.56 18.20±5.24 12.80±3.31 21.41±6.63 13.03±4.14 22.50±4.65 9.75±3.09 p=.034/F=2.721 p=.141/F=1.774

Mean±SD

Mean±SD

8.18±3.40 13.69±4.30 12.50±4.33 9.00±4.00 11.35±3.43 13.60±3.37 12.79±3.51 12.17±3.40 13.00±2.44 11.25±1.70 p=.011/F=3.471 p=.006/F=3.819

19.20±5.40 10.60±5.94 12.00±2.91 14.40±2.70 23.73±4.54 10.33±3.53 14.46±2.77 11.13±3.85 19.30±6.25 13.28±3.03 11.48±3.61 12.94±4.21 17.93±6.51 15.48±3.64 11.38±4.54 12.83±4.00 16.10±8.27 13.90±3.24 11.20±4.54 12.00±3.68 p=.028/F=2.853 p<.001/F=6.509 p=.108/F=1.952 p=.458/F=.916

18.93±6.38 13.60±3.79 27.25±1.70 11.50±5.06 p=.011/F=4.177 p=.286/F=.718

11.84±3.92 15.50±2.08 p=.069/F=1.704

12.80±4.05 10.75±2.98 p=.320/F=.684

19.00±6.47 13.30±3.67 19.65±6.60 13.47±4.31 p=.675/F=.019 p=.851/F=.2.531

11.97±4.06 11.52±3.62 p=.634/F=1.164

13.01±4.07 11.13±3.50 p=.048/F=.431

21.85±7.06 12.40±4.04 18.56±6.28 13.71±3.79 p=.044/F=.542 p=.175/F=.014

12.90±4.17 11.65±3.90 p=.210/F=.046

13.20±3.88 12.47±4.02 p=.470/F=.434

20.00±15.29 16.00±2.16 19.18±6.09 13.34±3.88 p=.809/F=21.142 p=.179/F=.1.991

19.51±6.40 13.41±3.80 14.66±7.63 14.00±5.05 p=.079/F=.181 p=.721/F=.991

14.00±8.04 11.81±3.76 p=.283/F=9.241

18.25±2.06 12.38±3.88 p=.003/F=2.325

12.12±3.88 12.53±4.00 8.33±3.98 14.00±3.74 p=.022/F=.012 p=.385/F=.789

SD: Standard deviation; *OneWay Anova test; **Independent sample t test.

example, arthritis, chronic lumbar pain, migraineheadache) want to die and feel helpless.[22] Because 60

of the difficulty in coping, elder individuals having pain may feel themselves helpless. The pain patients APRIL 2017


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who feel helplessness may see themselves inadequate, guilty, and worthless and this situation leads to depression in later stages. In these cases, nurses should develop methods to intervene by getting the patients express their emotions, develop trust relationships and help to increase the contact with the patientâ&#x20AC;&#x2122;s environment.[11,23] In our study, medical remedies subscore increased with the increasing helplessness subscore (Table 4). Similarly, Zamora&Clingerman (2011) have found that when elder individuals are able to cope with the pain symptoms, they usually try to get accustomed to the pain by carrying out social and physical activities instead of seeking for medical help.[24] Thus, by keeping in mind that individuals failing in pain management will have more tendency for seeking medical help, it is important for nurses not to fail to notice these patients as well as evaluating and supporting the coping methods of individuals believing that they are able to cope with the pain. In our study, medical remedies subscore was higher compared to conscious coping attempts subscore (Table 3). Moreover, medical remedies subscore was found to increase along with the increasing conscious coping attempts subscore (Table 4). Cornally and McCarthy (2011) have evaluated the attitudes of seeking help for chronic pain in elder individuals and have found that 83% use analgesics for pain management and 69% use analgesics frequently. Furthermore, authors have reported that the demand for medical help changes according to the cause of pain and in the patients believing that the pain is organic in nature, the demand is higher.[25] This may be explained as the coping methods preferred by elder individuals change in accordance with their beliefs about the pain. Accordingly, the preferred ways of coping with pain in the pain management could vary with regard to patientsâ&#x20AC;&#x2122; belief about pain. Therefore, nurses should assess patientsâ&#x20AC;&#x2122; belief about pains and should consider the pain patients who have organic pain beliefs can be directed to seek medical remedies. On the other hand, they should consider the pain patients who have psychological pain beliefs can also benefit from cognitive-behavioral interventions.[12] In addition, the fact that nurses give information related with the methods used in pain management can help patients select appropriate methods.[8] APRIL 2017

Comparison of Sociodemographic and Pain-Related Variables with PCQ Subscores In the study, medical remedies subscore was significantly higher in female patients compared to male patients. Babadag et al. have also reported similar results in algology patients aged under 65.[12] Accordingly, several studies have suggested that while pain sensitivity is higher, pain tolerance and painrelated self-efficacy are lower in females than males. [26] Moreover, females were found to report the pain more than males and this case has been suggested to be associated with cultural expectancy, social responsibilities and roles.[27] Sahin et al. have also reported that females tend to report the pain more than males and are more prone to the pain treatment.[28] Nurses should be particularly careful on the pain assessment of male patients considering they could seek medical remedies less than female patients.[12,27] In our study, there was a significant difference between the medical diagnosis of the patients and PCQ subscores. Particularly, patients having a very painful disease such as neuralgia had lower subscores of self-management, conscious coping attempts and medical remedies. Similarly, several previous studies have also found lower helplessness subscores and problems in coping with the pain in patients with neuralgia or migraine.[21] It is believed that medical diagnosis and disease story of the patients affect the pain severity and thus coping with the pain. There was also a significant difference between the site of pain and PCQ subscores in our study. The subscore of self-management was significantly lower in patients having pain in the head-neck region compared to those having pain in the back-lumbar region (Table 5). Several previous studies have also found similar results in migraine patients.[16] While nurses provide nursing care to the pain patients, they should consider the fact that coping status may change according to the cause of pain rather than the site of pain. On the other hand, in our study, patients using opioid drugs had significantly lower self-management subscore (p<0.05). Several studies have also suggested that patients do not prefer to use opioids, resulting in difficulties in the pain management. This was attributed to the fear about the side effects, the possibility of addiction, and inadequate information 61


A RI PAIN about the opioids.[29] The fact that nurses provide education to patients who use opioid drugs in the pain management on topics such as drug use, side effects and the effects of drug on the treatment could help increase adherence to treatment and will ensure success in pain management.[30] The subscore of self-management was significantly higher in our patients who had received a painrelated treatment compared to those who had not (Table 5). Koch et al. (2004) have found similar results and suggested that patients make their choices about the pain management with the trial-and-error method and according to their previous experiences. Furthermore, it has been suggested that patients determine the coping method appropriate for them by their previous experiences, their level of knowledge about the pain and the severity of the pain.[31] The fact that nurses evaluate the pain experience of patients, take the true pain history, and examine the methods and the results related with these methods that pain patients use to cope with the pain will help identify nursing interventions. In our study, the self-management subscore was significantly higher in patients believing that the control of pain is in their hands, besides, the subscore of medical remedies was also significantly higher in patients believing that it is in the hands of nurses (Table 5). Helmes and Gioburhun (2007) have used the Beliefs about Pain Control Scale in their study and the internal, external (physician etc.) and chance factors-related pain control were evaluated. In that study, the more the internal pain control, the less the helplessness; on the other hand, the more the control from external and chance factors, the more the helplessness feeling. Because internal control is believed to have positive effects on coping with the pain, internal control will improve individual coping ability with the pain.[32] Thus, it is important for nursing interventions to evaluate the belief of elder individuals about the pain control, to establish internal control in the patients and to use non-pharmacological methods such as cognitive-behavioral strategies (relaxation techniques, distraction etc.). The subscore of cognitive coping attempts was significantly higher in our patients having knowledge about pain compared to those not having (Table 5). 62

In the study by Dijkstra et al. (2001), the status of being prepared to self-coping with the chronic pain in fibromyalgia patients was examined and it has been found that although patients use the cognitive therapies in self-coping with the pain, these therapies are preferred by the patients only when they believe that they will benefit from it.[33] Although there are limited number of studies evaluating the efficacy of cognitive therapies in elder compared to younger individuals, some previous studies have reported beneficial effects in geriatric patients having pain.[34] Vitiello et al. (2009) have studied the effect of cognitive-behavioral therapy on the sleep and pain and found that this type of therapy increases the sleep quality and decreases the pain after a 1-year followup period.[35] Thus, it is important for nurses to help and inform the patients about coping methods with the pain. In conclusions; results of the present study suggest that the status of coping with the pain may differ among elderly pain patients. Nursing interventions should be planned by considering the methods of coping with the pain and associated factors in elder individuals. Also, in-service training programs should be provided to the nurses about these interventions. Elder individuals should be helped when making their choice about the most appropriate coping method by considering that helplessness decreases and the use of cognitive intervention increases in elder individuals having self-coping ability. Acknowledgments The authors would like to thank the staffs at Algology Clinic and all the patients who so willingly participated in the study. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

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• This study was presented at the 15th Euro Nursing & Medicare Summit in Rome/Italy on October 17–19, 2016.

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Agri 2017;29(2):64–70

doi: 10.5505/agri.2017.03789

A RI PAIN

ORIGINAL ARTICLE

Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain: Comparison of monopolar and bipolar modes Alt ekstremitenin iskemik ağrı tedavisinde radyofrekans termokoagülasyon: Monopolar ve bipolar modların karşılaştırması Dilek DESTEGÜL, Geylan IŞIK, Hayri ÖZBEK, Hakkı ÜNLÜGENÇ, Murat ILGINEL Summary Objectives: Radiofrequency thermocoagulation (RFT) has been reported to be used safely to treat ischemic lower extremity pain. The objective of the present study was to evaluate efficiency of RFT for treatment of lower extremity ischemic pain and to compare effectiveness of monopolar RFT and bipolar RFT modes. Methods: Following ethics committee approval, 30 American Society of Anesthesiologists classification I-III patients with ischemic lower extremity pain aged between 18 and 65 years were recruited. Patients were randomly allocated into 2 groups: MRT group (n=15) received monopolar RFT (80°C) for 2 minutes at L2-3 level, and BRT group (n=15) received bipolar RFT (80°C) for 2 minutes at L2-3 level. Systolic and diastolic blood pressure, heart rate, pain score, and supplemental analgesic requirements were recorded at 24 hours after application and at 7, 30, and 90 days. Results: Numerical rating scale values in both groups decreased significantly over time and it was found to be significantly lower in BRT group after first and third months (p<0.05). Supplemental analgesic requirements were similar with no significant difference between the 2 groups at any point of study period (p>0.05). No adverse event or complication related to procedure or treatment was reported. Conclusion: In patients with ischemic lower extremity pain, both monopolar and bipolar RFT treatment modalities were found to significantly decrease pain levels. However, bipolar mode led to lower pain scores at 30 and 90 days, and longer duration of analgesia than monopolar mode. Keywords: Radiofrequency thermocoagulation; monopolar; bipolar; ischemic pain; lumbar sympatholysis.

Özet Amaç: Alt ekstremitenin iskemik ağrı tedavisi için radyofrekans termokoagülasyon’un (RFT) güvenle kullanılabileceği bildirilmiştir. Bu çalışmanın amacı alt ekstremitenin iskemik ağrı tedavisi için RFT’un etkinliğini değerlendirmek ve monopolar ve bipolar RFT modlarını karşılaştırmaktı. Gereç ve Yöntem: Etik komite kabulünü takiben alt ekstremite iskemik ağrısı olan, yaşları 18–65 yaş arası, ASA I-III grubu, 30 hasta çalışmaya alındı. Hastalar MRT grubunda (n=15) L2-3 düzeyinden 2 dakika monopolar RFT (80°C), BRT grubunda (n=15) ise L2-3 düzeyinden 2 dakika bipolar RFT (80°C) almak üzere rastgele iki gruba ayrıldı. Sistolik ve diastolik kan basınçları, kalp atım hızı, ağrı skorları (NRS) ve ek analjezik ihtiyaçları hastaneden taburcu edildikten 24 saat ve 7, 30 ve 90. günlerde kaydedildi. Bulgular: Her iki grupta NRS skorlarının zaman içerisinde önemli derecede azaldığı ve BRT grubunda MRT grubuna göre 30 ve 90. günlerde istatistiksel olarak önemli derecede daha düşük olduğu tespit edildi (p<0.05). Bununla birlikte, ek analjezik ihtiyacının iki grupta benzer olduğu ve iki grup arasında çalışma periyodlarında istatistiksel fark oluşturmadığı tespit edildi (p>0.05). İşlem veya tedaviye ilişkin yan etki veya komplikasyon bildirilmedi. Sonuç: Alt ekstremitenin iskemik ağrı tedavisinde hem monopolar hem de bipolar radyofrekans termokoagülasyon tedavi modalitelerinin ağrı düzeylerini önemli derecede azalttığı bulundu. Bununla birlikte, bipolar RFT’un monopolar RFT’a göre 30 ve 90. günlerde daha düşük ağrı skorlarına ve daha uzun analjezi süresine neden olduğu belirlendi. Anahtar sözcükler: Radyofrekans termokoagülasyon, monopolar, bipolar, iskemik ağrı, lomber sempatolizis.

Department of Anesthesiology, Çukurova University Faculty of Medicine, Adana,Turkey Submitted (Başvuru tarihi) 27.06.2016 Accepted after revision (Düzeltme sonrası kabul tarihi) 05.04.2017

Correspondence: Dr. Hakkı Ünlügenç. Çukurova Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, 01330 Adana, Turkey. Phone: +90 - 322 - 338 67 42 e-mail: unlugenc@cu.edu.tr © 2017 Turkish Society of Algology

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APRIL 2017


Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain

Introduction Peripheral arterial disease (PAD) is characterized by an increased risk of vascular ischemic events. [1] The prevalence of PAD increases with age and the number of vascular risk factors (hypertension, diabetes, smoking, hyperlipidemia and high homocysteine levels).[2] Traditionally, non-invasive (controlling hypertension and diabetes, pharmacological treatment modalities) and invasive approaches (surgical or endovascular revascularization, with percutaneous balloon angioplasty, and with or without stenting) has been recommended for the treatment of pain in patients with PAD of lower extremities. However, for patients whose pain does not respond to appropriate medical and physical therapy, radiofrequency termocoagulation (RFT) has been proposed as an alternative treatment option for the treatment of pain in patients with peripheral arterial diseases.[1] In a pilot study, percutaneous radiofrequency thermal lumbar sympathectomy has been compared to phenol lumbar sympathetic neurolysis for the treatment of complex regional pain syndrome type 1.[3] In that study, authors have found that both treatment modalities are safe and effective procedures for providing satisfactory pain relief. The mechanism of action of RFT is to produce tissue destruction and lessen pain by modulating pain transmission.[4] Additionally it is also speculated that RFT may cause vasorelaxation in vessels when applied for lumbar sympathectomy and thus may reduce pain by producing lumbar sympatholysis.[4] RFT is firstly introduced in conventional (monopolar) mode and can be used in different modes. However, the major limitation of the monopolar RFT is its incapability to produce effective tissue destruction, without causing nerve damage.[5] To overcome the drawback of monopolar RFT, various techniques and modes have been proposed, including multiple probes RFT applied in the form of either simultaneous[6] or alternative RFT,[7] and bipolar RFT.[8–11] However, to date, as far as we know, there is no published data evaluating the efficiency of RFT for the treatment of lower extremity ischemic pain and compare the effectivity of monopolar RFT and bipolar RFT mode. APRIL 2017

In this prospective, double-blind, randomized study, we have evaluated the efficiency of RFT for the treatment of lower extremity ischemic pain and compare the effectivity of monopolar RFT and bipolar RFT mode on pain scores and analgesic consumption. Thus, the primary outcome of this study was considered as pain scores of patients measured by numerical rating scale at 24 hour, and 7, 30 and 90 days after hospital discharge.

Materials and Methods This prospective, double-blind, randomized study was conducted between 15 March 2013 and 15 September 2013 by Çukurova University, Faculty of Medicine, Department of Anesthesiology. Following faculty ethic committee approval and written patient consent 30 ASA I - II group patients between 18–65 years of age, undergoing lower extremity ischemic pain were included in this study. Exclusion criteria included significant coexisting disease such as cardiopulmonary disease, any contraindication to apply RFT such as local infection or bleeding disorders and long-term opioid use. Patients were instructed on the use of the numerical rating scale (NRS) for pain assessment and interventional procedure preoperatively. All patients were fasted for 8 h preoperatively and no premedication were given. Before intervention, patients were monitored with pulse oximetry, automated blood pressure cuff and lead II electrocardiogram, and an intravenous access was established. The patients were allocated to one of two groups of 15 each by computer-generated random number assignment. All procedures were performed in prone position. A pillow was inserted to correct lumbar spinal curve under lower abdomen and brought into a straight line at L₂-L₃ vertebra level. Transverse processes of the vertebra were marked and image of the transverse processes in C-arm fluoroscopy was rotated in oblique direction until imagine of transverse processes disappeared under the vertebral body. The area was cleaned with antiseptic, povidone iodine. After infiltrating the skin with 2% lidocaine 2 ml, a 15 cm active-curved radiofrequency needle 20 G (NeuroTherm) was introduced to the transverse (spinous) process of L2-L3 vertebral bodies under the guidance of a C-arm fluoroscopy. The position of the 65


A RI PAIN needle tip was also confirmed by C-arm fluoroscopy in lateral view. In bipolar mode, the second cannula was inserted at approximately 4–6 mm below of the first needle. Following negative aspiration for blood and cerebrospinal fluid testing, 1 mL of ionic radioopaque agent was given, which was also checked in the AP and lateral view. The correct placement of the needle/s was confirmed with the image contrast of straight line appearing vertically on the anterior face of corpus vertebra. Following confirmation of correct placement of the needle, radiofrequency stimulation was done at 50 Hz to identify proximity to motor (2 V) or sensory (0.5 V) nerves, respectively. No motor (fasciculation) or sensory (paresthesia) block was observed. Radiofrequency lesioning was applied in monopolar mode for 2 min at a temperature of 80°C in group MRT and in bipolar mode for 2 min with 4–6 mm intervals of two electrodes at a temperature of 80°C in group BRT. Ten milliliter of 0.25% bupivacaine was injected at each level after radiofrequency lesioning in both groups. No additional analgesic was administered unless requested by the patients. Systolic and diastolic blood pressures and heart rate variables were regularly monitored at preoperatively and during the procedure. All patients were observed routinely at postanesthesia care unit (PACU) for 4–6 hours postoperatively and discharged from PACU on the day of intervention when they met the discharge criteria. The discharge criteria for home were stable vital signs, awake and alert patient, no pain and other side effects. Patients were prescribed supplement analgesia with per orally (po) naproxen sodium 550 mg twice a day and allowed to take whenever they needed. Pain scores were evaluated preoperatively and at 24 hour, and 7, 30 and 90 days after hospital discharge. Pain was assessed using a numerical rating scale (NRS) ranging from 0 (no pain) to 10 (worst pain imaginable). Demographic data (Gender, age, weight, height and patients’ education) were recorded by an observer blinded to the treatment group. Pain scores, systolic and diastolic blood pressures (SBP, DBP) and heart rate (HR) were recorded by an investigator blinded to the patient group, at preoperatively, 24 hour, and 66

7, 30 and 90 days after hospital discharge. Supplement analgesic consumptions were questioned and recorded. All patients were also assessed in terms of adverse effects and complications. Patients were readmitted to hospital for general assessments and data collection (Hemodynamic variables, pain scores and supplement analgesic requirement) at 24 hour, 7, 30 and 90 days after hospital discharge. Statistical analysis The data were analyzed by using SPSS 20.0. Categorical measurements were summarized as number and percentage; continuous measurements were summarized as average and standard deviation. For the comparison of categorical variables, Chi-square test or Fisher exact test statistics were used. Distributions were controlled in continuously comparing the measurements between the groups. Eligibility of variables to normal distribution were examined visually (histograms and probability plots) and analytically (Kolmogorov-Smirnov/Shapiro-Wilk tests). Student T Test was used for the comparison of normally distributed parameters and Mann-WhitneyU test for the parameters which were not normally distributed. As normal distribution conditions could not be achieved in the comparison of repeated measurements such as NRS values, statistical significance of the change over time was carried out using the Friedman test for these parameters. The changes in the rate of additional analgesic requirements between the initial and subsequent tracking were evaluated by using Cochran Q test. The level of statistical significance (p value) was taken as 0.05 in all tests.

Results All patients completed the study protocol, n=15 in each group. The demographic variables (Gender, age, weight, height and patients’ education) of patients are shown in Table 1. There were no significant differences between groups in demographic variables. SpO2 values remained within the normal range during the intervention in both groups. SBP, DBP and HR values remained within the normal range throughout the study period. There were no statistically significant differences in hemodynamic variables between two groups (Table 2). Mean NRS scores significantly decreased over time. APRIL 2017


Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain

Table 1. Demographic variables of the patients

Group MRT (n=15)

n

%

Mean±SD

n

Group BRT (n=15) %

p

Mean±SD

Gender 9 60 9 60 p>0.05 Male 6 40 6 40 p>0.05 Female Age 49.2±9.2 51.2±12.1 p>0.05 Height 171±6.9 168.4±5.3 p>0.05 Weight 73.5±9.1 71.4±12.5 p>0.05 Education Primary school – – 4 26.6 p>0.05 Secondary school 6 40.0 4 26.6 p>0.05 High school 6 40 5 33.3 p>0.05 University 1 6.6 1 6.6 p>0.05 MRT: Monopolar Radiofrequency Thermocoagulation; BRT: Bipolar Radiofrequency Thermocoagulation; SD: Standard deviation.

Table 2. Hemodynamic variables in MRT and BRT groups

24 hour 7th days 30th days 90th days Mean±SD Mean±SD Mean±SD Mean±SD

SBP Group MRT 129.9±9.3 132.1±10.3 130.5±9.7 128.8±8.2 Group BRT 122.6±32 130.4±7.8 128.2±8.0 129.8±8.1 DBP Group MRT 74±6.5 77.6±5.5 78±7.4 75.7±6.8 Group BRT 72.2±6.3 74.7±5.5 74.2±5.8 75.2±6.5 HR Group MRT 76.3±5.9 77.2±5.4 76.3±5.8 75.8±5.1 Group BRT 73.8±4.5 73.8±6.9 76.2±5.1 75.4±5.6 MRT: Monopolar Radiofrequency Thermocoagulation; BRT: Bipolar Radiofrequency Thermocoagulation; SD: Standard deviation; SBP: Systolic blood pressures; DBP: Diastolic blood pressures; HR: Heart rate.

Table 3. Mean NRS scores in MRT and BRT groups NRS Scores

Group MRT Mean±SD

Group BRT Mean±SD

p

Preoperative 7.6±0.8 7.5±0.6 0.541 24 hour 5.7±1.3 6.4±1.4 0.130 7th days 4.5±1.2 4.4±1.5 0.705 th 30 days 4.4±1.9 2.6±0.9* 0.003 th 90 days 5.0±2.3 3.2±1.0* 0.035 NRS: Numerical rating scale; MRT: Monopolar Radiofrequency Thermocoagulation; BRT: Bipolar Radiofrequency Thermocoagulation. *p<0.05 statistically significant, compared with group MRT.

Although NRS scores was significantly lower in both groups at each study period than preoperative scores (p<0.001), there was no significant difference APRIL 2017

in pain scores between BRT and MRT groups at 24 hours and 7 days (p>0.05). However, it was significantly lower at the 30 and 90 days in BRT group than in MRT group (p<0.003, p<0.035) (Table 3). Number of patients requiring supplement analgesic also decreased over time. However there was no significant difference in analgesic requirement between two groups at each study period (p>0.05) (Table 4). No major complication or side effect related with procedure was reported and mostly (hypotension, nausea) were minor and resolved spontaneously.

Discussion The main object of the present study was to evaluate 67


A RI PAIN Table 4. Number of patients requiring supplement analgesic in MRT and BRT groups Number of patients requiring supplement analgesic Group MRT Group BRT p

24 7th 30th 90th hour days days days

>0.05 0.715 0.598 0.245

MRT: Monopolar Radiofrequency Thermocoagulation; BRT: Bipolar Radiofrequency Thermocoagulation ; Data are presented as number.

the efficiency of RFT for the treatment of lower extremity ischemic pain and compare the effectivity of monopolar RFT and bipolar RFT mode. We found that both RFT mode is effectively reduce pain scores in patients with lower extremity ischemic pain. However, bipolar mod led to lower pain scores at the 30 and 90 days and longer duration of analgesia than monopolar mode. When applied for sympatholysis, RFT may reduce pain by producing lumbar sympathectomy.[4] Kang and Umeda reported that lumbar sympathetic ganglia is most frequently found at the level of the upper third of the third lumbar vertebra, at the level of the lower third of the second lumbar vertebra and at the L2-3 interspace on both the right and left sides.[12,13] In the present study, the needles were introduced through the L2-3 intervertebral space under the guidance of C-arm fluoroscopy to make selective nerve destruction (lumbar sympatholysis) (evaluated by the stimulation of sensory and motor nerves). Radiofrequency lumbar sympatholysis has been proposed to have effective treatment option in patients with hyperhidrosis of lower limbs, sympathetically maintained pain, and vascular diseases.[14] For example, in the treatment of Raynaud’s disease, bipolar RF thermocoagulation within 7 mm intervals of the two electrodes has been used to produce sympatholysis. [12] In that case, sequential bipolar radiofrequency lumbar sympathectomy provided a long duration of symptom relief. In our study, in fact, both RFT modes provided effective analgesia in patients with lower extremity ischemic pain. However, BRT offered more beneficial effect in reducing pain scores in long time period than MRT because of the lower NRS scores after the first and third months. 68

Haynsworth and Noe compared the efficiency of RF thermocoagulation with chemical nerve destruction for the production of lumbar sympatholysis. They reported that percutaneous sympathectomy using RF thermocoagulation have a longer duration of analgesia and lower incidence of post-operative neuralgia, as compared to chemical nerve destruction.[15] Radiofrequency thermocoagulation impairs or destroys the nerves by creating heat to targeted nerve tissues and results in a disruption of the transmission of nerve function.[4] Conventional (monopolar) and bipolar RFT are the two basic types of radiofrequency thermocoagulation. Both of these methods have been shown to eliminate or reduce the chronic pain by disrupting pain signal transmission from specific nerves.[4] In the RFT treatment, semi-intact, a lesion in nerves is targeted from the tip of the RFT device, which disrupts the pain signal but not to cause necrosis in nerves. However, the lesion should also be large enough to produce long duration of analgesia. In the literature, in some cases, conventional monopolar RFT has been reported to fail to produce effective tissue destruction and lead to deafferentation pain during and after the application. Especially, in two studies, analysing the size of the thermal lesion created by RF under sonographic guidance, authors have stated that, there is a real need to increase the dimension of thermocoagulation using a single probe application.[5,16] To increase radiofrequency-induced coagulation, several investigators have proposed to use of bipolar radiofrequency thermocoagulation technique. Bipolar RFT may produce more predictable and larger lesions than monopolar RFT.[17–19] In bipolar mode, there is a high and constant electric field gradient between the two electrodes.[20] Anfinsen et al. compared the lesion size of bipolar and monopolar RFT techniques on porcine right atrium and reported greater lesion length in bipolar mode than unipolar mode.[19] Similarly, Pino et al. noted that bipolar RF created the largest lesion in performing thermocoagulation at 90oC for 120–150 seconds with 4–6 mm intervals of two electrodes.[21] Derby and Lee reported that bipolar electrodes produce greater thermocoagulation and better coagulation APRIL 2017


Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain

on a larger area than that of monopolar electrodes. [22] In our study, radiofrequency lesioning was created at a temperature of 80°C for 120 seconds in both groups. Bipolar RFT provided better pain scores at the 30 and 90 days, suggesting this technique produced greater thermocoagulation area than conventional monopolar RFT. Our findings are in accordance with other studies which also reported that bipolar radiofrequency thermocoagulation may create larger lesions than monopolar radiofrequency thermocoagulation using a bipolar RF-system with the two electrodes. [17–19] An explanation for this result may be that in bipolar RF modes, the first electrode is thermally shielded by the second electrode so that heat is trapped between the two probes and higher temperatures are achieved. This effect may produce higher temperatures and increase the dimension of thermocoagulation.[18] Wound healing and analgesia follows tissue destruction so we hypothesized that effective tissue destruction would result in lower pain scores and longer duration of analgesia. Thus, in the present study, better pain scores at the 30 and 90 days in bipolar RFT group implies bipolar RFT produced more effective tissue destruction, than monopolar RFT. In an experimental study, Bruners et al. investigated the differences between bipolar and monopolar radiofrequency (RF)-ablation devices regarding the shape and volume of the induced coagulation zone. They reported that if probes with 20 and 30 mm active tip length were used, the bipolar system creates more spherical lesion. In final, they concluded that the proper combination of RF-system and electrode length allows to individually adapting the shape and volume of the generated coagulation necrosis to the target lesion.[23] In the present study, we used a 15 cm active-curved radiofrequency needle (NeuroTherm) in both groups. Better pain scores at the 30 and 90 days and longer duration of analgesia in bipolar RFT group suggesting larger volume of coagulation was achieved with bipolar RFT mode. RFT can cause rare but serious complications such as abscess, cranial nerve palsies, blindness, meningitis and carotid-cavernous fistula.[24] In our study, APRIL 2017

no major complication or side effect was noticed. Minor side effects (hypotension, nausea) resolved spontaneously. There are two limitations of this study. The first; the sample size was not large enough to demonstrate a power as the study was conducted between 15 March 2013 and 15 September 2013. Another limitation was that recruited patients were not staged as to the level of claudication. Classification of the patients could be beneficial to provide the heterogeneity of the groups. In conclusion; both RF thermocoagulation technique (monopolar and bipolar) is effectively and safely used for the patients with lower extremity ischemic pain which need a long-term sympatholysis. However, bipolar RFT mod led to lower pain scores at the 30 and 90 days and longer duration of analgesia than monopolar mode, suggesting bipolar technique produced better thermocoagulation effect than conventional monopolar RFT. Further and large series of clinical studies are needed to confirm this relationship. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

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A RI PAIN technique: laboratory and clinical experience in liver metastases. Radiology 1998;209(2):371–9. 7. Lee JM, Rhim H, Han JK, Youn BJ, Kim SH, Choi BI. Dual-probe radiofrequency ablation: an in vitro experimental study in bovine liver. Invest Radiol 2004;39(2):89–96. 8. Burdío F, Güemes A, Burdío JM, Navarro A, Sousa R, Castiella T, et al. Bipolar saline-enhanced electrode for radiofrequency ablation: results of experimental study of in vivo porcine liver. Radiology 2003;229(2):447–56. 9. McGahan JP, Gu WZ, Brock JM, Tesluk H, Jones CD. Hepatic ablation using bipolar radiofrequency electrocautery. Acad Radiol 1996;3(5):418–22. 10. Curley SA, Davidson BS, Fleming RY, Izzo F, Stephens LC, Tinkey P, et al. Laparoscopically guided bipolar radiofrequency ablation of areas of porcine liver. Surg Endosc 1997;11(7):729–33. 11. Haemmerich D, Staelin ST, Tungjitkusolmun S, Lee FT Jr, Mahvi DM, Webster JG. Hepatic bipolar radio-frequency ablation between separated multiprong electrodes. IEEE Trans Biomed Eng 2001;48(10):1145–52. 12. Kang SS, Shin KM, Jung SM, Park JH, Hong SJ. Sequential bipolar radiofrequency lumbar sympathectomy in Raynaud’s disease -A case report-. Korean J Anesthesiol 2010;59(4):286–9. 13. Umeda S, Arai T, Hatano Y, Mori K, Hoshino K. Cadaver anatomic analysis of the best site for chemical lumbar sympathectomy. Anesth Analg 1987;66(7):643–6. 14. Chung YJ, Choi JB, Lee YW. Radiofrequency lumbar sympatholysis: comparison with neurolytic alcohol block. J Korean Pain Soc. 2004;17:42–46. 15. Haynsworth RF Jr, Noe CE. Percutaneous lumbar sympathectomy: a comparison of radiofrequency denervation versus phenol neurolysis. Anesthesiology 1991;74(3):459–63. 16. Goldberg SN. Radiofrequency tumor ablation: principles

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and techniques. Eur J Ultrasound 2001;13(2):129–47. 17. Nakada SY, Jerde TJ, Warner TF, Wright AS, Haemmerich D, Mahvi DM, et al. Bipolar radiofrequency ablation of the kidney: comparison with monopolar radiofrequency ablation. J Endourol 2003;17(10):927–33. 18. Wang YG, Lu ZY, Zhao HY, Song YE, Li RL. A comparative study of radiofrequency ablation in unipolar and bipolar fashion. J Tongji Med Univ 1995;15(2):73–6. 19. Anfinsen OG, Kongsgaard E, Foerster A, Aass H, Amlie JP. Radiofrequency current ablation of porcine right atrium: increased lesion size with bipolar two catheter technique compared to unipolar application in vitro and in vivo. Pacing Clin Electrophysiol 1998;21(1 Pt 1):69–78. 20. Haemmerich D, Tungjitkusolmun S, Staelin ST, Lee FT Jr, Mahvi DM, Webster JG. Finite-element analysis of hepatic multiple probe radio-frequency ablation. IEEE Trans Biomed Eng 2002;49(8):836–42. 21. Pino CA, Hoeft MA, Hofsess C, Rathmell JP. Morphologic analysis of bipolar radiofrequency lesions: implications for treatment of the sacroiliac joint. Reg Anesth Pain Med 2005;30(4):335–8. 22. Derby R, Lee CH. The efficacy of a two needle electrode technique in percutaneous radiofrequency rhizotomy:An investigational laboratory study in an animal model. Pain Physician 2006;9(3):207–13. 23. Bruners P, Lipka J, Günther RW, Schmitz-Rode T, Mahnken AH. Bipolar radiofrequency ablation: is the shape of the coagulation volume different in comparison to monopolar RF-ablation using variable active tip lengths? Minim Invasive Ther Allied Technol 2008;17(5):267–74. 24. Kanpolat Y, Savas A, Bekar A, Berk C. Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathic trigeminal neuralgia: 25-year experience with 1,600 patients. Neurosurgery 2001;48(3):524–32.

APRIL 2017


Agri 2017;29(2):71–78

doi: 10.5505/agri.2017.32549

A RI PAIN

ORIGINAL ARTICLE

Prevalence of and risk factors for low back pain among healthcare workers in Denizli Denizli’de sağlık çalışanlarında bel ağrısı prevelansı ve risk faktörleri Şule ŞIMŞEK,1 Nesrin YAĞCI,2 Hande ŞENOL3 Summary Objectives: The purpose of this study was to examine personal, occupational, and psychosocial risk factors affecting prevalence of low back pain in healthcare workers. Methods: Study included total of 1682 participants (1010 female, 672 male) working at Denizli State Hospital. Low back pain section of Standardized Nordic Musculoskeletal Questionnaire (SNMA) was used to evaluate recent occurrence, pain experienced within previous year, and over lifetime. Perceived Stress Scale and Job Satisfaction Scale were also administered. Results: Prevalence of lifetime low back pain in healthcare workers was determined to be 53% based on SNMA. It was observed that low back pain was most common among medical secretaries (56.9%). Advanced age, female gender, high body mass index (p=0.002), being married (p=0.0001), lack of regular exercise (p=0.009), working for more than 4 hours while standing (p=0.012) or sitting at desk (p=0.021), using computer for more than 4 hours (p=0.0001), greater number of years of service (p=0.001), and low job satisfaction (p=0.001) were found to be factors increasing low back pain risk. Conclusion: Our study demonstrated that healthcare workers are among group with high risk of low back pain. Keywords: Healthcare workers; low back pain; prevalence; risk factors.

Özet Amaç: Sağlık çalışanlarında bel ağrısı prevalansını, etkileyen kişisel, işle ilişkili ve psikososyal risk faktörlerini incelemektir. Gereç ve Yöntem: Çalışmamıza Denizli Devlet Hastanesi’nde görev yapan, çalışmaya katılmayı kabul eden 1010 kadın ve 672 erkek toplam 1682 katılımcı dâhil edildi. Nokta ve yıllık prevalansın değerlendirilmesinde Standardize Nordik Muskuloskeletal Anketinin (SNMA) genel bölümünde yer alan bel ağrısı ile ilgili kısım kullanıldı. Psikososyal faktörlerin değerlendirilmesi kapsamında, katılımcıların stres düzeyi ‘Algılanan Stres Ölçeği’, iş memnuniyeti ‘İş Doyum Ölçeği’ kullanılarak gerekli veriler elde edildi. Bulgular: Sağlık çalışanlarında yaşam boyu bel ağrısı prevalansı %53 olarak saptandı. En fazla bel ağrısının tıbbi sekreterlerde (%56,9) olduğu tespit edildi. İleri yaş, kadın cinsiyet, Vücut Kitle İndeksinin (VKİ) yüksek olması (p=0,002), evli olmak ve egzersiz alışkanlığının olmaması (p=0,009), ayakta durarak (p=0,012) ve oturarak 4 saatten fazla çalışma (p=0,021), 4 saatten fazla bilgisayar kullanma (p=0,001), artmış hizmet yılı (p=0,001) ve iş memnuniyetinin az olması (p=0,001) bel ağrısı riskini artıran faktörler olarak saptandı. Sonuç: Çalışmamız sağlık çalışanlarının bel ağrısı açısından yüksek risk grubunda olduğunu göstermiştir. Anahtar sözcükler: Sağlık çalışanları; bel ağrısı; prevalans; risk faktörleri.

Introduction Pain is a psychologically challenging physiological function with a vital importance and disturbing the life quality of the person, preventing the person to be productive, and causing sleeping disorders.[1] Low back

pain is a very common disorder in all societies causing workforce losses. It is ranked as the fifth reason for consulting a physician.[2] Low back pain issues have been encountered as a health problem in all historical ages and its history goes back to B.C. 1500.[3] Low back pain

Department of Physical Therapy and Rehabilitation, Denizli State Hospital, Denizli, Turkey Pamukkale University School of Physical Therapy and Rehabilitation, Denizli, Turkey 3 Department of Statistics, Hacettepe University, Ankara, Turkey 1 2

Submitted (Başvuru tarihi) 01.03.2016 Accepted after revision (Düzeltme sonrası kabul tarihi) 05.04.2017

Correspondence: Dr. Nesrin Yağcı. Pamukkale Üniversitesi Fizik Tedavi ve Rehabilitasyon Yüksekokulu, Denizli, Turkey. Phone: +90 - 258 - 296 42 76 e-mail: nesrinyagci@yahoo.com © 2017 Turkish Society of Algology

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A RI PAIN is witnessed in all cultures and ethnic groups.[4] It is observed that the point prevalence is 12–33%, annual prevalence is 22–65% and lifetime prevalence is 11–84% in all studies on low back pain.[5–7] It is demonstrated that there are various risk factors affecting the incidence and prevalence of low back pain in the epidemiological studies performed. These risk factors are divided into 3; as personal, occupational and psychosocial.[8,9] Age, gender, body mass index, family history, smoking, alcohol usage a physical activity level can be listed among personal risk factors. Sudden physical load, bending forwards, twisting, heavy lifting, exposure to vibration and staying in the same posture for long periods of time can be counted among the occupational risk factors.[9] The relation between low back pain and depression can be explained with neurological mechanisms. It affects the response mood to the painful physical stimulus caused via serotonin and norepinephrine in the brain.[10] Persons stating that their job was boring, monotone or non-satisfactory in terms of psychosocial risk factors complain from low back pain at a higher level.[11] It is reported that depression and anxiety are among the important risk factors in patients with chronic low back pain.[12] Majority of healthcare professionals has the risk of musculoskeletal system disorders. The risk groups of low back pain among healthcare professionals are physicians, dentists, nurses, physiotherapists, laboratory workers and caregivers.[13] Our study is planned for the purpose of examining the low back pain prevalence and effects of personal, occupational and psychosocial risk factors among healthcare workers at Denizli State Hospital.

Materials and Methods Study design and participants Our study included a total of 1682 participants working at Denizli State Hospital, of whom 1010 were female and 672 were male, and who accepted to participate in the study. Our samples consisted of medical secretaries, physicians, nurses, allied health personnel and caregivers. Our study is approved by Non-Invasive Clinical Studies Ethics Committee of Pamukkale University (03.03.2015/03). All participants filled out a Voluntary Approval Form before the study. 72

Our research was performed by applying the sociodemographic question forms consisting of questions such as age, gender, height, weight, marital status, family history, smoking and exercising habits of all participants within a two-month-long period. Point and annual prevalence was determined by questioning the presence of complaints within the last 7 days and 12 months, which is in the general section of Standardized Nordic Musculoskeletal Questionnaire. Pain localized between the gluteal region and last rib, and felt in the dorsal region requiring therapy or persisting all day long for at least two weeks is considered as low back pain in our study. Outcome measures Assessment of pain Pain level of participants was evaluated with the 10-cm-long Visual Analogue Scale (VAS). (0: no pain, 10: most severe pain). Also the duration of complaint, starting age of first low back pain, reporting sickness live due to pain, absenteeism from work within last year, the clinic applied for therapy and most common treatment method were questioned. Assessment of occupational risk factors Participants’ professions, years of service, working types, daily working hours, times spent by standing and sitting, presence of breaks, times spent by using computer, load carriage situations and how much it is if present were questioned via the questionnaire method. Assessment of psychosocial risk factors Stress levels of participants were evaluated with “Perceived Stress Scale”. Reliability study of this scale was performed by Örücü et al. in 2009. Participants are asked to mark the most appropriate option in the questionnaire consisting of 10 questions. 5 point likert scale is used in the scoring where “0=none, 4=very often”. 4 positive subjects are reversed and scored in the scale. Total score is between 0 and 40 points. High score indicates that stress is high.[14] Job Satisfaction Scale was used to evaluate the job satisfaction of participants. This scale was developed to determine the job satisfaction levels of individuals. There are 10 questions with 4 options in the scale. Participants are asked to mark the option reflecting APRIL 2017


Prevalence of and risk factors for low back pain among healthcare workers in Denizli

their situation the best. Answers to the questions in the scale are scored between 1 and 4. Lowest point to get from the scale is 10, highest point is 40. Low points indicate the job dissatisfaction.[15] Statistical analysis A statistical software package (SPSS 21.0, Chicago, IL) was used to perform all analyses. Continuous and categorical data are reported as mean±standard deviation and number (percentages), respectively. To determine risk factors of low back pain, the binary logistic regression method was used. Independent groups were statistically analyzed by using the Independent Samples t-test, Mann Whitney U test and Chi-square test. Statistical significance was set at p<0.05.

Results 188 medical secretaries, 764 nurses, 215 physicians, 238 allied health personnel and 277 caregiver participated in the study. 1010 of 1682 employees were female and 672 of them were male. Age average was 37.9±7.46 years and average working years was 16.29±8.26 years (Table 1). Lifetime low back pain prevalence was 53%, annual prevalence was 39% and point prevalence was 29.5% among healthcare professionals (Figure 1). It was determined that the profession with the highest prevalence was medical secretarial (56.9%). 52.8% of participants had mild pain within the last year whereas acute pain level was 5.92 cm and chronic pain level was 5.45 cm (Table 2). Pain level was high between ages 36–45 in women and between ages 46–55 in men (Figure 2). Average complaint duration of participants with low back pain was 36.39 + 37.2 months, age of first low back pain incidence was found as 31.7 + 6.32 years. 33% of the participants suffering from low back pain got sickness live due to pain. Among hospital employees, most consulted clinic was the physiotherapy clinic and the most common treatment was drug therapy (Table 2). When individual risk factors were examined, it was determined that elder age, female gender (p=0.041), high body-mass index (BMI) (p=0.002), being married (p=0.0001) and lack of exercising habit (p=0.009) increased the low back pain risk (Table 3). APRIL 2017

Working for more than 4 hours by standing (p=0.012) and sitting (p=0.021), using computer for more than 4 hours (p=0.0001) and increased years of service (p=0.003) affect the risk of having low back pain significantly as the occupational risk factors of low back pain. In our study, it has been determined that the ones working for 4–8 hours by standing have 0.145 times more risk and the ones working for more than 8 hours by standing has 0.185 times more risk when compared to the ones working for less than 4 hours by standing. The ones working for 4–8 hours by sitting has 4.7 times more risk when compared to the ones working for less than 4 hours by sitting. Each 1 unit increase in years of service increases the risk of low back pain by 0.93 times, whereas low back pain risk in people using computer for more than 4 hours is 0.005 times more. When the effects of stress and job satisfaction on low back pain are examined as psychosocial risk factors, there is a meaningful relation determined between low job satisfaction and low back pain (p=0.001). 1 unit decrease in job satisfaction score increases the low back pain risk by 1.11 times (Table 3).

Discussion Low back pain, ranked as second among the diseases causing workforce loss in developed countries, is the most important factor affecting the production loss. Occupational low back pain developed as a result of exposure to factors such as heavy lifting, working by bending forwards, using the waist and body in wrong positions, and improper working conditions is a common cause of injury.[16] It is considered that the low back pain is more frequent today as a result of decreased body movements despite the spread of technology.[17] Because of this, research on low back pain frequency and risk factors has an important place in preventing low back pain. Hospital employees encounter more occupational health problems than other professionals, and the most common of them is low back pain.[7] Our study is planned for the purpose of examining the personal, occupational and psychosocial risk factors affecting the low back pain prevalence of healthcare workers at Denizli State Hospital. In our study, lifetime low back pain prevalence of healthcare workers was determined as 53% and 73


A RI PAIN Table 1. Demographics and clinic data of the participants by groups Characteristics

Group I Low back pain (n=892)

Group II No low back pain (n=790)

Mean±SD

Mean±SD

Age (year) BMI (kg/cm²) Working year Daily working hours Standing working time Sitting on working time Computer usage (h) PSS score JSS score

39.39±6.75 25.47±2.81 17.76±7.66 8.70±1.34 5.54±2.68 3.61±2.16 2.95±2.25 22.19±5.63 15.28±2.46

36.13±7.82 24.88±3.10 14.62±8.58 8.75±1.55 5.59±2.88 3.54±2.22 2.88±2.48 20.00±6.26 16.41±3.17

p*

0.0001 0.0001 0.0001 NS** NS** NS** 0.002 0.0001 0.0001

n % n % pa

Gender NS Male 341 38.2 331 41.9 Female 551 61.8 459 58.1 Occupation NS Physician 116 13 99 12.5 Nurse 407 45.6 357 45.2 Medical secretary 107 12 81 10.3 Allied health staff 128 14.4 110 14 Caregiver 134 15 143 18 Marital status 0.0001 Never married 192 21.5 195 24.68 Married 620 69.5 574 72.66 Divorced 80 9.0 21 2.66 Family history 0.028 Yes 565 63.3 459 58.1 No 327 36.7 331 41.9 Smoking habit NS Yes 366 41 355 44.9 No 526 59 435 55.1 Physical exercise 0.0001 Regular 241 27 284 35.9 No exercise 651 73 506 64.1 Rest break NS Yes 626 70.2 567 71.8 No 266 29.8 223 28.2 Load carrying 0.0001 Yes 360 40.4 185 23.4 No 532 59.6 605 76.6 SD: Standard deviation; PSS: Perceived Stress Scale; JSS: Job Satisfaction Scale; NS: Not significant; h: Hour; *Mann Whitney U Test; **t Test; ªChi Square Test

the annual prevalence was determined as 39% and point prevalence was determined as 29.5%. Low 74

back pain prevalence is 76% in the Netherlands,[18] 70.9% in Kuwait,[19] 57.7% in Tunisia,[7] 46% in IceAPRIL 2017


Low back pain responder rate (%)

Prevalence of and risk factors for low back pain among healthcare workers in Denizli

100 90 80 70 60 50 40 30 20 10 0

53 39 29

Life-time prevalance

Annual prevalance

Point prevalance

Figure 1. Life – time, annual and point prevalence of low back pain on health care workers.

land and Nigeria[20,21] and 38.9% in Hong Kong[22] in the literature. Altınel et al. found the lifetime low back pain prevalence as 47% and annual low back pain prevalence as 34.3% among 268 healthcare professionals.[23] In a study by Arasan et al. where

they examined the low back pain frequency in 478 nurses working at a private hospital, lifetime low back pain prevalence was determined as 84% and point prevalence was determined as 63%.[24] Low back pain was determined among 39.9% of 163 nurses working at two different state hospitals in Bandırma.[25] Lifetime low back pain prevalence was 65.8% and annual prevalence was 61.3% among 1600 healthcare professionals.[17] Also, in the study where the relation between low back pain frequency and chronic fatigue syndrome was examined, frequency in the last 12 months was determined as 59.7%.[26] In our study, pain present between the gluteal region and last rib, and felt in the dorsal region requiring treatment or lasting all day long for at least two weeks was considered as low back pain. There are publications in the literature where mechanical pain in the low back region, pain radiating

Table 2. Pain characteristics and pain-related behaviors of the study sample Pain characteristics Number(current pain) Pain intensity Mild Moderate Severe Acute pain intensity** (n=496) Chronic pain intensity** (n=655) Pain duration (month)** Onset of pain (age)**

Total

Males

Females

p*

n % n % n % 655

254 38.8 401 61.2 0.0001

109 16.6 59 9 50 7.6 346 52.8 142 21.7 204 31.1 200 30.5 53 8.1 147 22.4 5.92 1.74 5.19 1.64 5.64 1.85 5.45 1.78 5.55 1.58 6.14 1.79 36.39 37.25 37.99 39 35.39 36.12 31.71 6.72 32.43 5.13 31.25 6.91

0.0001ª 0.001ª 0.0001ª NS 0.0001ª

Pain-related behaviors Get reported because of low back pain Yes No Referenced department Orthopedics Physical Therapy Neurosurgery No any department Treatment Medicine Physiotherapy Surgery No treatment

291 32.6 130 14.6 161 18 601 67.4 211 23.7 390 43.7 0.0001 188 21.1 103 30.2 85 15.4 381 42.7 129 37.8 252 45.7 272 30.5 78 22.9 194 35.2 51 5.7 31 9.1 20 3.6 529 59.3 203 59.5 326 59.2 266 25.3 91 26.7 135 24.5 54 6.1 12 3.5 42 7.6 83 9.3 35 10.3 48 8.7

0.0001

NS

NS: Not significant; *Chi - Square test; **Mean (SD); ªMann-Whitney U test.

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VAS (cm)

10 9 8 7 6 5 4 3 2 1 0 Age

Female

6.29

6.22 4.76

21–35 years

Male 7.19 5.55

5.50

36–45 years

46–55 years

Figure 2. The relation between age and pain intensity.

Table 3. Results from regression model of risk factors for low back pain

p

OR(Exp B) 95% CI

Individual risk factors Gender 0.041* Body mass index 0.002* Marital status 0.000* Smoking habit 0.311 Physical exercise 0.009* Workplace risk factors Working time 0.003* Daily working hours 0.350 Standing working time 0.012* Sitting on working time 0.021* Computer use 0.0001* Load carrying 0.553 Psychosocial risk factors Higher job satisfaction 0.001* Workplace stress 0.142

1.2 0.9 0.2 0.8 0.7

1.00–1.52 0.91–0.98 0.16–0.44 0.72–1.10 0.59–0.92

0.9 1.0 0.1 4.7 0.0 1.2

0.90–0.97 0.92–1.24 0.03–0.65 1.25–17.64 0.00–0.04 0.63–2.31

1.1 0.9

1.04–1.18 0.95–1.00

OR: Odds ratio; CI: Confidence interval; *p<0.05.

through hips and legs was considered as low back pain.[23,27–29] These differences in the prevalence values can be associated with the definition of low back pain. When the low back pain frequency was evaluated based on occupational groups, it was witnessed that the riskiest occupational group consisted of nurses. [10,23,28–30] In the study of Terzi et al. it was determined that the occupational group encountering low back pain the most consisted of medical secretaries.[26] In our study, low back pain was mostly witnessed among medical secretaries (56.9%). The fact that the participation of medical secretaries was higher and professionally they work for longer periods of time 76

by sitting explains why low back pain was witnessed in higher ratios than other occupational groups. There are different results on individual risk factors in the literature. Altınel et al. noted that smoking and family history were risk factors for low back pain.[23] In a study performed on operating room nurses in Saudi Arabia there wasn’t any relation determined between pain level and age, gender, smoking habit, BMI.[28] In the study by Wong et al. where they examined the risk factors among healthcare professionals working at different hospitals, there wasn’t any meaningful relation determined between individual risk factors and low back pain.[29] In the study where risk factors among hospital employees were evaluated with the non-parametric approach, it was witnessed that height, weight, gender and extra professional activities increased the frequency of low back pain.[16] According to Karahan et al., age, female gender and smoking habit are among risk factors.[17] İlhan et al. examined the relation between age and low back pain prevalence; and they reported that low back pain was 1.95 times more in age group 25– 34, 3.32 times more in age group 35–44, 3.31 times more in age group 44–55 when age group 15–24 was used as a reference.[31] When individual risk factors were examined in our study, it was determined that elder age, female gender, high BMI, being married and lack of exercising habit increased the risk of low back pain. According to Altınel et al. when occupational risk factors were examined, the unit worked at, working duration and working shifts weren’t effective, whereas there were differences in terms of occupational tasks. [23] There wasn’t any meaningful relation witnessed between occupation type and service year, and low back pain.[28] Wong et al. reported that professional category, faulty posture, heavy lifting were risk factors among healthcare professionals working at different hospitals.[29] In another study, it was determined that occupation, daily working hours, working time by standing and sitting were determined as risk factors.[16] In Sweden, working environment with bad lighting and ventilation, maintaining the same position for a long time, load carrying and working for more than 8 hours a day were found as risk factors for low back pain among university hospital employees.[30] Karahan et al. reported that occupational APRIL 2017


Prevalence of and risk factors for low back pain among healthcare workers in Denizli

group and load carrying increased the frequency of low back pain.[17] In our study, it was determined that working by standing and sitting for more than 4 hours, using computer for more than 4 hours and increased years of service affect the low back pain risk significantly. High job demands and low job satisfaction were demonstrated as psychosocial risk factors as a result of Meta Analysis studies in literature.[32] In the study where Perceived Stress Scale and Job Content Questionnaire were used, it was emphasized that arrangements should be considered for personal and psychosocial factors in addition to arrangements for occupational factors.[33] In another study, depression and limitation were determined as independent risk factors.[10] Even though prevention and protection strategies for nurses in the working environment are addressed to ergonomic risk factors, it was noted that improving psychosocial work environment might have the effect of decreasing musculoskeletal disorders.[34] We have determined a meaningful relation between low job satisfaction and low back pain. This study has demonstrated that lifetime low back pain prevalence of healthcare workers was 53%, annual prevalence was 39% and point prevalence was 29.5%. The occupation with most frequent low back pain was determined as the medical secretarial (56.9%). When risk factors were examined, we have determined a meaningful relation between low back pain and elder age, female gender, high Body Mass Index (BMI), being married and lack of exercise habit, working for more than 4 hours by standing and sitting, using computer for more than 4 hours, increased years of service and low job satisfaction. Limitations Limitations of our study were the unequal number of occupational groups and not determining the risk factors of different occupational groups. Conclusions Making necessary regulations regarding working in a constant position for a long time, building ergonomic working conditions, encouraging people towards exercise among hospital employees will contribute to decreasing the low back pain incidence ratio. APRIL 2017

Acknowledgements We thank for Denizli Government Hospital staff for help with participating in our study. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

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Karimlou M, et al. Low back pain prevalence and associated factors in Iranian population: findings from the national health survey. Pain Res Treat 2012;2012:653060. 28. Keriri HM. Prevalence and risk factors of low back pain among nurses in operating rooms, Taif, Saudi Arabia. American Journal of Research Communication 2013;1(11):45– 70. 29. Wong TS, Teo N, Kyaw MO. Prevalence and risk factors associated with low back pain among health care providers in a district hospital. Malaysian Orthopaedic Journal 2010;4(2):23–8. 30. Genevay S, Cedraschi C, Courvoisier DS, Perneger TV, Grandjean R, Griesser AC, et al. Work related characteristics of back and neck pain among employees of a Swiss University Hospital. Joint Bone Spine 2011;78(4):392–7. 31. İlhan MN, Aksakal FN, Kaptan H, Ceyhan MN, Durukan E, İlhan F, et al. Birinci basamakta yaşam boyu bel ağrısı sıklığı ve ilişkili sosyal ve mesleksel risk etmenleri. Gazi Tıp Degisi 2011;21(3):107–10. 32. Macfarlane GJ, Pallewatte N, Paudyal P, Blyth FM, Coggon D, Crombez G, et al. Evaluation of work-related psychosocial factors and regional musculoskeletal pain: results from a EULAR Task Force. Ann Rheum Dis 2009;68(6):885–91. 33. Govindu NK, Babski-Reeves K: Effects of personal, psychosocial and occupational factors on low back pain severity in workers. Int J Ind Ergon 2014;44:335–41. 34. Bernal D, Campos-Serna J, Tobias A, Vargas-Prada S, Benavides FG, Serra C. Work-related psychosocial risk factors and musculoskeletal disorders in hospital nurses and nursing aides: a systematic review and meta-analysis. Int J Nurs Stud 2015;52(2):635–48.

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Agri 2017;29(2):79–81

doi: 10.5505/agri.2015.24654

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CASE REPORT

Primary headache associated with sexual activity: A case report Seksüel aktivite ile ilişkili primer baş ağrısı: Olgu sunumu Tuba ÖZCAN, Esra YANCAR DEMIR, Murat Doğan İŞCANLI Summary Headaches provoked by triggering factors have been recognized for many decades. In many cases, the development of such headaches is secondary to an underlying pathology. However, in some cases, no abnormality can be identified. Primary headache associated with sexual activity (PHASA) is one of the subgroups of primary headaches. PHASA is a benign form of headache and lifetime prevalence is estimated to be 1% to 1.6% in the general population. A 38-year-old man was admitted to outpatient clinic reporting history of severe headaches during sexual intercourse for the last 2 months. Headaches occurred bilaterally in occipital area just after orgasm and lasted for about 2 hours. Propranolol 40 mg/ day was initiated and on followup, patient reported dramatic improvement in 2 weeks. Treatment was maintained for 6 months. Patient has been on regular follow-up for a year and had no recurrence of headache. This is a rare case PHASA. In this patient, prophylactic treatment with low dosage of propranolol was successful. Keywords: Headache; propranolol; sexual activity.

Özet Tetikleyici faktörlerle ortaya çıkan baş ağrıları onyıllardır bilinmektedir. Birçok hastada, bu tür baş ağrıları altta yatan bir patolojiye sekonder olarak gelişmektedir. Ancak, bazı hastalarda herhangi bir sorun tespit edilememektedir. Seksüel aktiviteyle ilişkili primer baş ağrısı (SAPB) primer baş ağrılarının bir alt grubudur. SAPB selim bir başağrısıdır ve genel popülasyonda yaşam boyu prevelansı %1–1.6’dır. Otuz sekiz yaşında erkek hasta, 2 aydır olan cinsel aktivite sırasında ortaya çıkan ciddi baş ağrısı nedeniyle polikliniğimize başvurdu. Ağrısı orgazm sonrası her iki oksipital bölgede ortaya çıkıyor ve yaklaşık 2 saatte sonlanıyordu. Hastaya 40 mg/gün propranolol başlandı ve 2 hafta içinde dramatik şekilde düzelme bildirdi, tedaviye 6 ay devam edildi. Bir yıldır düzenli kontrollerine devam eden hastada yeniden baş ağrısı olmadı. Bu olguda nadir görülen SAPB ve düşük doz propranolol ile başarılı tedaviyi bildirmek istedik. Anahtar sözcükler: Baş ağrısı; propranolol; seksüel aktivite.

Introduction Headaches provoked by triggering factors have been recognized for many decades.[1–3] In many cases, the development of such headaches is secondary to an underlying pathology.[4,5] However, in some cases, no abnormality can be identified. Primary headache associated with sexual activity (PHASA) is one of the subgroup of primary headaches. Firstly, in 1960s a benign form of headache during sexual activity was recognized.[6] PHASA is a benign form of headache and lifetime prevalence estimated to be 1–1.6% in the general population.[7,8] The mean age at onset usually occurs in the third or fourth decade of life. The aetiology remains unclear. That may be seen in both genders, and prognosis is good.[8,9]

Here, we report a patient with PHASA with a dramatic response to low dosage of propranolol.

Case Report A 38-year-old man was admitted to our outpatient clinic reporting a history of severe headache during sexual intercourse for the last 2 months. He had never had similar headaches in the past. He had a history of gastritis. He was experiencing headache bilaterally in occipital area just after orgasm and then it lasted about in 2 hours. There was no accompanying symptom such as nausea, vomiting, photophobia, phonophobia or osmophobia. The headache was unresponsive to analgesic drugs. Physical and

Department of Neurology, Ordu University Faculty of Medicine, Ordu, Turkey Submitted: 17.06.2015 Accepted after revision: 17.09.2015 Available online date: 26.12.2016

Correspondence: Dr. Tuba Özcan. Ordu Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Cumhuriyet Yerleşkesi, Ordu, Turkey. Phone: +90 - 0452 - 226 52 00 e-mail: dr_aydemir@yahoo.com © 2017 Turkish Society of Algology

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A RI PAIN neurologic examinations were unremarkable. Routine laboratory investigations were in normal range. Magnetic resonance imaging and magnetic resonance angiography were normal. He was diagnosed as primary PHASA. Indomethasine at an increasing dose, starting at 25 mg/day up to 100 mg/day, was prescribed, whereas there was no response and gastric symptoms were increased. Therefore, propranolol 40 mg/day was started, on follow up which he noted a dramatic improvement in two weeks, and treatment was maintained for six months. He has been on regular follow-up for a year, and his headache did not repeat.

Discussion We report a case of PHASA which is a rare primary headache. The diagnosis of PHASA requires the exclusion of secondary causes of headache. In our case, neurological, labarotory and brain imaging studies were all normal. In this report, we describe a patient with a PHASA, who showed a dramatic response to a prophylactic treatment with propranolol 40 mg/ day. The International Headache Society divides the PHASA into two subtypes: Type 1 (pre-orgasmic): a dull ache in the head and neck that occurs during sexual activity and increases with sexual excitement. Type 2 (orgasmic): sudden and severe, similar to thunderclap headache, which occurs at orgasm. Type 2 is the most common type of PHASA.[10,11] A diagnosis of type 2 PHASA was made for our patient. The exact pathophysiology of PHASA is unknown. Howeever, muscular component and impaired cerebrovascular autoregulation have been supposed to be raleted with PHASA.[8] In our case MRI and MRA have revealed nor vasospasm neither any other pathologies. Primary headaches associated with sexual activity has a male preponderance [4/1], the mean age at onset usually occurs in young people. The duration of the headache also varies from just a few minutes to hours. In most patients the pain is bilateral. An association was suggested between sex-related headaches and migraine. This relationship is more frequent with type 2 with a prevalance of 25–47%. [9,12] Our patient did not have any other headache. 80

The course of PHASA is variable, sometimes occurring at regular intervals, and sometimes occurring sporadically. Ostergaard et al. followed the clinical course of 26 patients; some patients experienced only an isolated episode or a single cluster of sexual headaches, whereas others had several episodes.[13] Silbert et al. reported that in the majority of their patients headache disappeared without any treatment.[9] With regard to treatment as a preventive step, indomethacin (25–100 mg/day), propranolol (40–240 mg/day), naratriptan (2.5 mg) have been reported to be effective.[9,11] It has been shown that good efficacy of short-term prophylaxis with indomethacin 25–100 mg 1–2 h before intercourse.[9,12] For long-term prophylaxis, beta-blockers (propranolol 120–240 mg/ day, metopropolol 100–200 mg/ day and diltiazem 180 mg/day) found to be effective aproximately in 80% of the patients.[14] Prophylaxis can be sufficient for a period of 2–6 months bacause of spontaneous remission. In a patient, it was reported that single greater occipital nerve injection with steroid and local anaesthetic was effective.[15] Bandini et al. reported an excellent response to 50 mg/day topiramate in their patient with type 1 PHASA.[16]

Conclusion Primary headaches associated with sexual activity are rare conditions and usually have a benign selflimiting course. Once secondary causes have been excluded, the prognosis is good and should be explained to the patient. This is a rare case of primary headache associated with sexual activity. In this patient, prophylactic treatment with low dosage of propranolol was successful. Conflict-of-interest issues regarding the authorship or article: None declared. Peer-rewiew: Externally peer-reviewed.

References 1. Rooke ED. Benign exertional headache. Med Clin North Am 1968;52(4):801–8. 2. Paulson GW, Klawans HL Jr. Benign orgasmic cephalgia. Headache 1974;13(4):181–7. 3. Symonds C. Cough headache. Brain 1956;79(4):557–68. 4. Pascual J, González-Mandly A, Martín R, Oterino A. Head-

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Primary headache associated with sexual activity aches precipitated by cough, prolonged exercise or sexual activity: a prospective etiological and clinical study. J Headache Pain 2008;9(5):259–66. 5. Yeh YC, Fuh JL, Chen SP, Wang SJ. Clinical features, imaging findings and outcomes of headache associated with sexual activity. Cephalalgia 2010;30(11):1329–35. 6. Wolff HG. Headache and other pain. New York: Oxford University Press, 1963. p. 493–4. 7. Rasmussen BK, Olesen J. Symptomatic and nonsymptomatic headaches in a general population. Neurology 1992;42(6):1225–31. 8. Frese A, Eikermann A, Frese K, Schwaag S, Husstedt IW, Evers S. Headache associated with sexual activity: demography, clinical features, and comorbidity. Neurology 2003;61(6):796–800. 9. Silbert PL, Edis RH, Stewart-Wynne EG, Gubbay SS. Benign vascular sexual headache and exertional headache: interrelationships and long term prognosis. J Neurol Neurosurg Psychiatry 1991;54(5):417–21. 10. Headache Classification Committee of the International Headache Society. The International Classification of

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Headache Disorders, 2nd edition. Cephalalgia 2004;24(Suppl 1):1–160. 11. Evers S and Lance JW. Primary headache attributed to sexual activity. In: Olesen J, et al. (eds) The headaches, 3rd edn. Philadelphia, PA: Lippincott Williams and Wilkins, 2006. p. 841–5. 12. Pascual J, Iglesias F, Oterino A, Vázquez-Barquero A, Berciano J. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996;46(6):1520–4. 13. Ostergaard JR, Kraft M. Ostergaard JR1, Kraft M. Benign coital headache. Cephalalgia 1992;12(6):353–5. 14. Frese A, Gantenbein A, Marziniak M, Husstedt IW, Goadsby PJ, Evers S. Triptans in orgasmic headache. Cephalalgia 2006;26(12):1458–61. 15. Selekler M, Kutlu A, Dundar G. Orgasmic headache responsive to greater occipital nerve blockade. Headache 2009;49(1):130–1. 16. Bandini F, Arena E, Mauro G. Pre-orgasmic sexual headache responsive to topiramate: a case report. Cephalalgia 2012;32(10):797–8.

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Analjeziklere dirençli kronik baş ağrısının nadir bir nedeni: İzole sfenoid sinüs aspergilloması A rare cause of analgesic-resistant chronic headache: Isolated aspergilloma of the sphenoid sinus Emre GÜNBEY,1 Kerim ASLAN,2 Hediye Pınar GÜNBEY,2 Rıfat KARLI,1 Şemsettin KARDAŞ1 Özet Sfenoid sinüs hastalıklarının tanısı nonspesifik öykü ve fizik muayene bulguları nedeniyle zordur. Sfenoid sinüs, aspergillomaların en nadir görüldüğü lokalizasyondur ve tanıdaki gecikmeler ciddi komplikasyonlar ile sonuçlanabilir. Burada uzun yıllardır uyku bozukluğu ve baş ağrısı nedeni ile psikiyatri bölümünce takip edilmekte olan bir sfenoid sinüs aspergilloması olgusunu sunuyor ve bu nadir olgu ile beraber sfenoid sinüs aspergillomalarının klinik ve radyolojik özelliklerini tartışıyoruz. Anahtar sözcükler: Aspergilloma; baş ağrısı; sfenoid sinüs.

Summary The diagnosis of sphenoid sinus diseases is difficult due to nonspecific history and physical examination findings. Sphenoid sinus is a rare localization for aspergilloma. Delay in diagnosis and treatment can result in serious complications. Presently described is case of sphenoid sinus aspergilloma. Patient had been treated by department of psychiatry for many years due to sleep disturbances and headache. Clinical and radiological features of rare case of sphenoid sinus aspergilloma are discussed. Keywords: Aspergilloma; headache; sphenoid sinus.

Giriş Paranazal sinüslerin fungal enfeksiyonları immün yetmezliği olmayan sağlıklı insalarda nadir görülmektedir. Fungal sinüs enfeksiyonları arasında en sık görülen patojenlerden biri aspergillosistir ve Aspergillus fumigatus en sık görülen alt türdür. Aspergillosis en sık maksiller sinüste ve daha az sıklıkla etmoid ve frontal sinüslerde görülmektedir. Sfenoid sinüs ise aspergillomaların en nadir görüldüğü lokalizasyondur.[1,2] İzole sfenoid sinüs hastalıkları nadir görülen, non spesifik öykü ve fizik muayene bulguları nedeni ile tanısı zor olan hastalıklardır. Bununla beraber bu hastalıkların tanı ve tedavisindeki gecikmeler, sfenoid sinüsün önemli nörovasküler yapılara yakın kom-

şuluğu nedeni ile görme kaybı, menenjit gibi ciddi komplikasyonlara neden olabilmektedir.[3] Bu yazıda, uzun yıllardır uyku bozukluğu ve baş ağrısı nedeni ile psikiyatri bölümünce takip edilmekte olan bir sfenoid sinüs izole aspergilloma olgusu sunuldu.

Olgu Sunumu Elli beş yaşında erkek hasta yaklaşık 10 yıldır devam eden baş ağrısı ve uyku bozukluğu yakınması ile başvurdu. Öyküsünden ağrının daha çok kafasının arka kısımlarında ve ensesinde olduğu, daha önce baş ağrısı nedeniyle birçok kez antibiyotik ve analjezik ilaçlar kullandığı ancak fayda görmediği öğrenildi. Eşlik eden başka sistemik hastalığı olmayan hastaya

Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Kulak Burun Boğaz Anabilim Dalı, Samsun Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Samsun 1 Department of Otorhinolaryngology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey 2 Department of Radiology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey 1 2

Başvuru tarihi (Submitted) 30.06.2015 Düzeltme sonrası kabul tarihi (Accepted after revision) 22.10.2015 Online yayımlanma tarihi (Available online date) 26.12.2016

İletişim (Correspondence): Dr. Emre Günbey. Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Kulak Burun Boğaz Anabilim Dalı, Kurupelit, 55139 Samsun, Turkey. Tel (Phone): +90 - 362 - 312 19 19 e-posta (e-mail): emregunbeymd@hotmail.com © 2017 Türk Algoloji Derneği

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Analjeziklere dirençli kronik baş ağrısının nadir bir nedeni: İzole sfenoid sinüs aspergilloması (a)

(b)

Şekil 1. Hastanın preoperatif sagital (a) ve aksiyel (b) paranazal BT görüntülerinde sağ sfenoid sinüs içerisinde yer yer kalsifikasyonlar içeren kitle lezyonu ve sinüs duvarında destrüksiyon izlendi. (Yıldız: sfenoid sinüsteki kitle; H: Hipofiz bezi; Ok: Sfenoid sinüs üst duvarındaki destrüksiyon).

(a)

(b)

bu yakınmaları nedeniyle psikiyatri bölümünce medikal tedavi başlanmıştı. Hastanın nazal endoskopiyi de içeren ayrıntılı kulak burun boğaz muayenesinde patolojik bulgu izlenmedi. Hastanın paranazal sinüs bilgisayarlı tomografisinde (BT) sağ sfenoid sinüste sinüs duvarlarında ekspansiyona neden olan, sfenoid sinüs arka duvarını destrükte eden ve hipofiz bezi ile sınırları net ayırt edilemeyen, dorsum sellada yaylanmaya neden olan, santrali hiperdens etrafı hipodens ve yer yer kalsifikasyonlar içeren kitle lezyonu izlendi. BT’de ayrıca bilateral maksiler sinüslerde ve sağ etmoid hücrelerde seviye oluşturan hipodens yumuşak doku değerleri mevcuttu (Şekil 1). Kitlenin hipofiz ile ilişkisini ortaya koymak ve natürü hakkında bilgi edinebilmek için paranazal sinüs ve hipofiz magnetik rezonans görüntüleme (MRG) yapıldı. MRG’de sfenoid sinüsü ekspanse eden yaklaşık 19x17 mm boyutlarında T2 ağırlıklı sekanslarda hipointens, T1 ağırlıklı sekanslarda hiperintens kitlesel lezyon izlendi. Sfenoid sinüs tavanının ise tamamen destrükte olduğu gözlendi (Şekil 2). Hastaya bu bulgularla genel anestezi altında endoskopik sinüs cerrahisi yapıldı. Operasyonda orta konka medialinden sfenoid sinüs doğal ostiumu tanımlanarak, genişletildi. Sfenoid sinüs içerisinde sarımtırak, peynirimsi, görünüm ve kıvam olarak fungal enfeksiyonu düşüdüren kitle lezyonu mevcuttu. Patolojik dokular sfenoid sinüs mukozasından diseke edilerek temizlendi. Arka duvardan diseke edilirken arka duvarın alt yarısında kemik defekt olduğu görüldü (Şekil 3). Buradaki patolojik dokular tamamen temizlendikten sonra durada bir defekt saptanmaması üzerine sfenoid sinüs ile ilgili ek bir işleme gerek duyulmadı. Takiben bilateral maksiller

(c)

Şekil 2. Hastanın preoperatif T1 ağırlıklı koranal (a), sagital (b) ve T2 ağırlıklı koronal (c) MR kesitleri. Sağ sfenoid sinüste ortası T1 ağırlıklı sekanslarda hiperintens, T2 sekansında hipointens etrafı mukozal kalınlaşma ile çevrili lezyon.

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(b)

Şekil 3. İntraoperatif endoskopik görünüm. (a) Sağ sfenoid sinüsü dolduran sarımtırak, peynir kıvamında lezyon görülmekte. (b) Lezyon temizlendikten sonra sfenoid sinüsün görünümü. (Oklar: Sfenoid sinüs arka duvarındaki kemik defekti; Tek yıldız: Lateral nazal duvar; a: Aspergillomaya ait doku; Çift yıldız: Nazal septum).

antrostomi yapılarak ameliyat komplikasyonsuz olarak tamamlandı. Histopatolojik inceleme sonucunda aspergilloma tanısı alan hastanın postoperatif 6. aya kadar kontrollerinde nüks saptanmadı ve başağrıları tamamen geriledi.

Tartışma Aspergillus türleri doğada sık rastlanan mantarlardır. Aspergillusun, alt türlerinden fumigatus, flavus, niger ve terreus’un insanda enfeksiyona yol açtığı saptanmıştır.[4] Fırsatçı aspergillus enfeksiyonları klinik olarak noninvaziv, invaziv veya alerjik tipte görülebilir. Daha çok immün yetmezliği olan kişilerde görülen aspergillus enfeksiyonları nadir olmakla beraber sağlıklı insanlarda miçetoma, aspergilloma veya mantar topu olarak tanımlanan noninvaziv enfeksiyona neden olabilir.[5] Paranazal sinüslerin aspergillus mikozu ilk olarak 1885’te Schubert tarafından tanımlanmıştır.[6] Paranazal sinüslerin aspergillomaları sıklıkla tek sinüste ve en sık maksiller sinüste görülür. En az görüldüğü lokalizasyon ise sfenoid sinüstür.[2] 1992 yılından önce sadece 21 sfenoid sinüs aspergilloma olgusu bildirilmesine karşın, görüntüleme yöntemlerinin gelişmesi ve yaygınlaşması ile beraber rapor edilen olgu sayısında büyük artışlar yaşanmıştır.[2] Sfenoid sinüs hastalıkları nadir görülmekle beraber, sfenoid sinüsün önemli nörovasküler yapılar ile yakın komşuluğu bu hastalıkların çok ciddi komplikasyonlara yol açmalarına sebep olmaktadır. Optik sinir, internal karotid arter, hipofiz bezi, kavernöz sinüs, III., IV., VI. kranial sinirler ve V. kranial sinirin oftalmik (V1) ve maksiller (V2) dalları gibi önemli yapılar sfenoid sinüsle yakın ilişki içerisindedir. Bu nedenle, sfenoid sinüs hastalıkları tanı ve tedavide geç kalındığında çok ciddi komplikasyonlara yol açabilmektedir.[7] Bizim olgumuzda ise 84

intrakranial bir komplikasyon gelişmemekle beraber, sfenoid sinüs arka duvarı tamamen destrükte olmuş ve mantar topu dura ile ilişki içerisindeydi. Sfenoid sinüs hastalıklarının nonspesifik öykü ve fizik muayene bulgularının olması bu hastalığın tanısını zorlaştırmaktadır. İzole sfenoid sinüs aspergilloması nedeni ile takipli 30 hastada yapılan retrospektif bir çalışmada hastaların %80’inde baş ağrısı, %26’sında yüzde ağrı, %23’ünde geniz akıntısı ve %16’sında görme kaybı ve çift görme gibi visüel semptomlara rastlanmıştır.[8] Ayrıca baş ağrısının iyi lokalize edilememekle beraber en sık frontal ve retrobulber bölgede olduğu görülmüştür. Hastalarda baş ağrısı ve beraberinde görülebilecek nörolojik semptomların sıklığı, hastaların yaklaşık %80’inin ilk olarak nöroloji veya nöroşirürji kliniklerine baş vurmasına neden olmaktadır.[9] Bizim olgumuzda ise hasta başağrısını net lokalize edememekle birlikte daha çok ense bölgesinde tarif ediyordu. Sfenoid sinüs aspergillomalı hastalara yapılan endoskopik muayenede, hastaların %86.7’sinde nonspesifik bulgulara, %10’unda mukopürülan akıntıya ve %3.3’ünde sfenoetmoid resesin (SER) önünde polipoid yapılara rastlanmıştır.[8] Bizim olgumuzda da olduğu gibi nazal endoskopi bulgularının normal olması, sfenoid sinüs patolojisini ekarte ettirmemektedir.[3] Sfenoid sinüs lezyonlarının yayılımını, natürünü ve komşu anatomik yapılar ile olan ilişkisini BT ve MRG ile görüntülemek mümkündür.[7] Fawaz ve ark. yaptıkları retrospektif bir çalışmada; BT’nin sfenoid sinüs fungal enfeksiyonlarının tanısında %100 sensitiviteye fakat %71 spesifiteye sahip olduğunu; MR’ın ise %21 sensitiviteye, %100 spesifiteye sahip APRIL - NİSAN 2017


Analjeziklere dirençli kronik baş ağrısının nadir bir nedeni: İzole sfenoid sinüs aspergilloması

olduğunu göstermişlerdir.[10] Sfenoid sinüs aspergillomalı hastalarda yapılan başka bir çalışmada ise hastalarda en sık görülen BT bulgularının total opasite, SER obstrüksüyonu, sinüs duvarlarında kalınlaşma, intralezyonel kalsifikasyon ve sinüs duvarlarında erezyon olduğu bildirilmiştir.[8] Benzer şekilde, bizim olgumuzda hastaya çekilen paranazal BT’de sağ sfenoid sinüste, sinüs duvarlarında destrüksiyona ve ekspansiyona neden olan, sfenoid sinüs tavanını erode etmiş, mikrokalsifikasyonlar içeren kitlesel lezyon izlenmişti. Kitlenin içeriği hakkında daha ayrıntılı bilgi edinmek için hastaya paranazal bölgeye yönelik MR görüntüleme yapıldı. Sfenoid sinüs aspergillomalarının tedavisinde en etkili yöntem endoskopik sinüs cerrahisidir.[9,11] Endoskopik cerrahi ile sfenoid sinüs lezyonlarına kolaylıkla müdahale edilebilmekte, sinüse ulaşılarak alınan aspirasyon örnekleri ve doku biyopsileri ile tanı desteklenmekte, hastalıklı dokular temizlenebilmektedir.[7] Sfenoid sinüs miçetomalarının tedavisinde kitlenin çıkarılması ve tıkanan ostiumun açılarak sinüsün havalanmasının sağlanması genellikle yeterlidir. Sistemik antifungal tedavi veya ek bir tedaviye ihtiyaç yoktur. İnvaziv aspergillus sinüziti ise yüksek mortalite ve morbidite ile seyreder.[12,13] Bu hastalardaendoskopik yolla yapılacak debridman ve amfoterisin B, varikonazol veya itrakonazol gibi sistemik antifungal ajanların kullanılması ile başarılı sonuçlar alınabilir.[12,14]

Sonuç Sfenoid sinüs hastalıklarının tanısında ilk basamak şüphelenmektir. Uzun süreli, medikal tedaviye yanıtsız, iyi lokalize edilemeyen baş ağrısı şikayeti olan bir hastada nazal muayenesi doğal olsa bile ayırıcı tanıda izole sfenoid sinüs patolojileri akla gelmelidir. BT ve MRG tanı ve tedavinin planlanması için en önemli tetkiklerdir. Tedavide endoskopik yaklaşımla eksizyon çoğu zaman tedavi ve komplikasyonların önlenmesinde yeterli olmaktadır.

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Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması (conflict of interest) yoktur. Hakem değerlendirmesi: Dış bağımsız.

Kaynaklar 1. Kameswaran M, al-Wadei A, Khurana P, Okafor BC. Rhinocerebral aspergillosis. J Laryngol Otol 1992;106(11):981–5. 2. Scamoni C, Dario A, Fachinetti P, Marra A, Villa P, Cerati M, et al. Isolated aspergillosis of the sphenoid sinus. Case report. J Neurosurg Sci 1992;36(2):107–10. 3. Sethi DS. Isolated sphenoid lesions: diagnosis and management. Otolaryngol Head Neck Surg 1999;120(5):730–6. 4. Khongkhunthian P, Reichart PA. Aspergillosis of the maxillary sinus as a complication of overfilling root canal material into the sinus: report of two cases. J Endod 2001;27(7):476–8. 5. Chao TK. Triple discrete fungus balls of the paranasal sinuses. Otolaryngol Head Neck Surg 2004;131(6):1014–5. 6. Pinzer T, Reiss M, Bourquain H, Krishnan KG, Schackert G. Primary aspergillosis of the sphenoid sinus with pituitary invasion - a rare differential diagnosis of sellar lesions. Acta Neurochir (Wien) 2006;148(10):1085–90. 7. Grillone GA, Kasznica P. Isolated sphenoid sinus disease. Otolaryngol Clin North Am 2004;37(2):435–51. 8. Jung JH, Cho GS, Chung YS, Lee BJ. Clinical characteristics and outcome in patients with isolated sphenoid sinus aspergilloma. Auris Nasus Larynx 2013;40(2):189–93. 9. Ruoppi P, Seppä J, Pukkila M, Nuutinen J. Isolated sphenoid sinus diseases: report of 39 cases. Arch Otolaryngol Head Neck Surg 2000;126(6):777–81. 10. Fawaz SA, Ezzat WF, Salman MI. Sensitivity and specificity of computed tomography and magnetic resonance imaging in the diagnosis of isolated sphenoid sinus diseases. Laryngoscope 2011;121(7):1584–9. 11. Gilony D, Talmi YP, Bedrin L, Ben-Shosan Y, Kronenberg J. The clinical behavior of isolated sphenoid sinusitis. Otolaryngol Head Neck Surg 2007;136(4):610–5. 12. Dhong HJ, Chung SK, Koh SJ. Isolated sphenoid sinus disease. Korean J Otolaryngol 1998;41:467–70. 13. Karatas A, Is M, Guclu E, Dosoglu M, Gezen F. Intracranial epidural abscess secondary to isolated sphenoid sinusitis. Br J Neurosurg 2007;21(6):616–8. 14. Browning AC, Sim KT, Timms JM, Vernon SA, McConachie NS, Allibone R, et al. Successful treatment of invasive cavernous sinus aspergillosis with oral itraconazole monotherapy. J Neuroophthalmol 2006;26(2):103–6.

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OLGU SUNUMU / CASE REPORT

Antihistaminik kullanımı ile tetiklenen tekrarlayıcı baş ağrısı ve reversible serebral vazokonstriksiyon sendromu Reversible cerebral vasoconstriction syndrome and recurrent headache triggered by antihistamine use Sibel GÜLER, Ufuk UTKU, Canan ÇELEBI Özet Reversibl serebral vazokonstriksiyon sendromu (RSVS), Call-Fleming sendromu olarak da bilinen, genellikle 20–40 yaşlarında ve kadınlarda görülen, nörolojik defisitlere neden olabilen gök gürültüsü baş ağrısının nadir nedenlerinden biridir. RSVS nedeni muhtemelen serebral vasküler tonustaki geçici disregülasyonun neden olduğu multifokal arteriyal konstriksiyon ve dilatasyondur. Altmış üç yaşında kadın hasta başının sol tarafında belirgin, ani gelişen, tekrarlayıcı baş ağrısı şikayeti ile başvurdu. Fizik ve nörolojik muayenesi normaldi. Kraniyal manyetik rezonans görüntüleme (MRG) anjiyo incelemelerinde MCA ve PCA’da belirgin olmak üzere damarların distallerinde belirgin vazokonstriksiyon saptandı. Ayırıcı tanıda ilk olarak düşünülen primer SSS anjitisi kranial MRG’de parankim lezyonu ve beyin omurilik sıvısında (BOS) protein artışı olmaması nedeniyle dışlandı. Deksametazon sodyum fosfat 4 mg/ml (4 mg/gün) ve nimodipin 90 mg/gün tedavisi başlandı. Nimodipin dozu kademeli olarak 120 mg/gün’e çıkarıldı. Ek olarak, antihistaminik ajanların kesilmesi ile baş ağrısı belirgin olarak geriledi. RSVS sendromunun vurgulanması gereken en önemli özelliğinin benzer klinik prezentasyon gösteren subaraknoid kanama veya primer santral sinir sistemi (SSS) anjitisinden farklı olarak klinik bulgularının reversibl olmasıdır. Klinik bulgular çoğunlukla düzelmekle birlikte, kalıcı nörolojik defisitler de olabileceği göz önünde bulundurulmalıdır. Anahtar sözcükler: Antihistamin kullanımı; baş ağrısı; reversibl serebral vazokonstriksiyon sendromu; tekrarlayıcı.

Summary Reversible cerebral vasoconstriction syndrome (RCVS), also known as Call-Fleming syndrome, is one of the rare causes of thunderclap headaches, which are most often seen in females aged 20–40 years and which can cause neurological deficits. The cause of RCVS is thought to be multifocal arterial constriction and dilatation caused by transient disregulation of cerebral vascular tonus. Presently described is case of 63-year-old female patient who presented with complaint of sudden onset of recurrent headaches located on the left side. Physical and neurological examinations were normal. Cranial magnetic resonance imaging (MRI) angiography examination showed vasoconstrictions in the distal, particularly in middle cerebral arteries and posterior cerebral arteries. Primary angitis of central nervous system (CNS), first considered in differential diagnosis, was excluded because no parenchymal lesion was seen in cranial MRI and no protein increase was observed in cerebrospinal fluid. Dexamethasone sodium phosphate 4 mg/mL (4 mg/day) and nimodipine 90 mg/day treatment was initiated. Nimodipine dose was gradually increased to 120 mg/day. Headache resolved significantly after discontinuation of antihistaminic agents. The most important feature of RCVS to be highlighted is that clinical signs are reversible, unlike subarachnoid hemorrhage or primary angitis of CNS, which have similar clinical presentations. Although clinical signs of RCVS usually resolve, it should be considered that permanent neurological deficits may occur. Keywords: Antihistamine use; headache; reversible cerebral vasoconstriction syndrome; recurrent.

Giriş Reversibl serebral vazokonstriksiyon sendromu (RSVS) tekrarlayıcı gök gürültüsü baş ağrısı ve serebral arterlerdeki reversibl daralma ile ilişkilidir.

Multifokal vasokonstriksiyon yaklaşık olarak 2–3 ay içerisinde düzelmektedir. RSVS sık olarak kadınlarda ve 40–50 yaş civarında ortaya çıkmaktadır.[1] RSVS etiyolojisi sekonder yada idiopatik olabilir. Uyuşturucu

Trakya Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Edirne Department of Neurology, Trakya University Faculty of Medicine, Edirne, Turkey Başvuru tarihi (Submitted) 26.08.2015 Düzeltme sonrası kabul tarihi (Accepted after revision) 16.12.2015 Online yayımlanma tarihi (Available online date) 26.12.2016

İletişim (Correspondence): Dr. Sibel Güler. Trakya Üniversitesi Tıp Fakültesi, Nöroloji Anabilim Dalı, Edirne, Turkey. Tel (Phone): +90 - 284 - 444 07 28/2422 e-posta (e-mail): drsibelguler@yahoo.com © 2017 Türk Algoloji Derneği

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Antihistaminik kullanımı ile tetiklenen tekrarlayıcı baş ağrısı ve reversible serebral vazokonstriksiyon sendromu

Şekil 1. Kranial MRI anjio’da orta serebral arter ve posterior serebral arterlerin distallerinde belirgin vazokonstriksiyon izlenmiştir.

veya serotonin geri almı inhibitörleri gibi vazoaktif maddelerin kullanımı RSVS’nin sekonder nedenleri arasındadır. RSVS benign nedenler dışında klinik (fokal nörolojik defisit, nöbetler) ve radyolojik (kortikal SAK, intrakranial kanama, iskemik inme, arteriyel diseksiyon ve posterior reversibl ensefalopati sendromu) anormallikler ve artmış mortalite ve morbidite ile ilişkili olabilir.[2,3] Burada baş ağrısının nadir nedenlerinden biri olan ve ayırıcı tanısı oldukça önemli olan RSVS tanısı alan bir olgu, etiyolojide farklı olarak antihistaminik kullanımının olması ve nüks göstermesi dolayısıyla sunuma değer görüldü.

Olgu Sunumu Altmış üç yaşında kadın hasta başının sol tarafında belirgin, ani gelişen tekrarlayıcı baş ağrısı şikayeti ile başvurdu. Başağrısının yaklaşık 10 gün öncesinde Moksifloksasin 400 mg/gün kullanımına bağlı anaflaktik reaksiyon geçirdiği belirtildi. 43 yıllık aurasız migren tanısı olan fakat düzenli profilaktik ilaç kullanımı olmayan sadece atak sırasında naproksen sodyum ya da parasetamol kullanımı bulunan hastanın, yaklaşık 3 yıl önce benzer vasıfta yaklaşık 1.5 ay süren baş ağrısı şikayeti olduğu öğrenildi. Bu atağı ile ilgili olarak adını hatırlamadığı ancak antihistaminik olması muhtemel ilaç kullanımı tarif eden hasta, başka bir tetikleyici faktör belirtmedi. Fizik muayenesinde özellik saptanmayan olgunun nörolojik muayenesi normaldi. Tam kan sayımı, biyokimya, C-reaktif protein, sedimentasyon hızı, tiroid fonksiyon testleri (TFT) normal sınırlardaydı. BOS incelemesinde basınç 16 cm H2O, protein 50.2 mg/dl iken, hücre saptanmadı. Kraniyal MRG anjiyo incelemelerinde MCA ve PCA’da belirgin olmak üzere damarların distallerinde belirNİSAN - APRIL 2017

gin vazokonstriksiyon saptandı (Şekil 1). Ayırıcı tanıda ilk olarak düşünülen primer SSS anjitisi Kranial MRG’de parankim lezyonu ve BOS’da protein artışı olmaması nedeniyle dışlandı. Graves ve Hashimoto ensefalopatisi RSVS ile benzer kraniyal görüntüleme bulguları oluşturmakla birlikte olgumuzda TFT ve anti-tiroid peroksidaz (anti-TPO) ve anti-troglobulin antikorları negatifti. Hastanın şikayetlerinin öncesinde anaflaktik reaksiyon öyküsü bulunması ve sonrasında kullandığı ilaçların vazoaktif ilaçlar olması dolayısıyla RSVS tanısı konuldu. Deksametazon sodyum fosfat 4 mg/ml (4 mg/gün) ve nimodipin 90 mg/gün tedavisi başlandı. Nimodipin dozu kademeli olarak 120 mg/gün’e çıkarıldı. Şikayetlerinde kısmen düzelme gözlenen hastanın, RSVS etiyolojisin de rol oynadığı düşünülen antihistaminik ajanların (Feniramin maleat 54.4 mg/gün) kesilmesi ile baş ağrısı belirgin olarak geriledi. Kontrol amaçlı yaklaşık 1.5 ay sonra çekilen MRG anjiyo’da MCA ve PCA’da gözlenen vazokonstriksiyonun düzeldiği gözlendi (Şekil 2).

Tartışma Call-Fleming sendromu nadir görülen ve ilk kez 1988’de tanımlanan bir sendromdur.[4] Bu sendrom, klinik ve radyolojik bulgu veren şiddetli akut baş ağrısı izlenen ve dalgalı seyir gösteren nörolojik bir durumdur. Anjiyografik olarak intrakranial arterlerde reversibl segmental veya multifokal segmental vazospazm ile karakterizedir.[5,6] RSVS’de genel olarak normal nörolojik muayene ve BOS bulguları eşlik eder. Ancak 60 yaşından genç hastalarda önemli bir inme nedeni de olabilmektedir.[5] RSVS’nin patofizyolojisi net olarak bilinmemektedir. Literatürde vazoaktif ilaç kullanımı sonrası RSVS gelişimi ile ilgili vakalar bildirilmiştir.[7] Vakaların %60’ı 87


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Şekil 2. Kontrol kranial MRG anjiyo’da orta serebral arter ve posterior serebral arterlerin distallerindeki vazokonstriksiyonun gerilediği görülmektedir.

postpartum dönemdedir yada vazoaktif ajanlar ile etkileşim gibi sekonder nedenler bulunmaktadır. Ana klinik semptom 1–3 hafta süren genellikle bulantı, kusma, fotofobi, konfüzyon ve bulanık görmenin eşlik ettiği nükseden, ani gelişen ve şiddetli (gök gürültüsü) baş ağrısıdır.[8] Majör komplikasyonlar konveksitede lokalize anevrizmal olmayan subaraknoid hemoraji (%22) ve kalıcı nörolojik defisite neden olabilen iskemik inme ya da intraserebral hemorajidir.[9] Literatürde RSVS tanısı alan benzer olgular incelendiğinde; 23 yaşında kadın hasta ekstazi ve esrar (marijuana) gibi maddelerin kullanımı sonrasında gök gürültüsü baş ağrısı, kusma ve nöbet şikayetleri ile başvurmuştur. Muayenesinde bulanık görme ve fotofobi saptanmıştır.[10] Hastanın BT’sinde SAK bulgusu saptanmaz iken lomber ponksiyon incelemesinde ksantokromi ile uyumlu bulgular saptanmıştır. BT anjiyografisinde ise 2.7 mm çapında sol karotid oftalmik arter anevrizması saptandığı ve tanısal amaçlı yapılan serebral anjiografide ise orta, anteriyor ve posteriyor serebral arterler ve posteriyor inferiyor serebral arter dallarında madde kullanımına bağlı geliştiği düşünülen RSVS ile uyumlu bulgular bildirilmiştir.[10] Diğer bir RSVS olgusu ise öyküsünde depresyon, aurasız migren ve esrar kullanımı bulunan 32 yaşında kadın hastadır.[11] Hasta triptanlara yanıtsız gökgürültüsü başağrısı şikayeti ile başvurmuştur. Görüntülemelerinde bilateral oksipital infarkt, bilateral ekstrakraniyal vertebral arter diseksiyonu, bilateral internal karotid arter dissekan anevrizması ve RSVS’yi destekler şekilde anteriyor ve posteriyor intrakraniyal damarlarda distal multifokal segmental daralma saptanmıştır.[11] Baziler arterde de distal trombüs saptanan hastaya, oral antikoagülan tedavisi başlandığı ve sekelsiz olarak iyileştiği bildirilmiştir.[11] 88

RSVS tanısı invaziv ya da noninvaziv olarak serebral anjiyografi ile segmental arterlerde daralma ya da dilatasyon gözlenmesine dayanır.[9] Katater anjiyografi altın standart testtir. Transkraniyal Doppler ise vazospazm takibinde kullanılabilmektedir.[7] Gök gürültüsü baş ağrısı ile birlikte görülen diğer olaylar; anevrizmal SAK, intraserebral hemoraji, serebral venöz tromboz, serviko-serebral arter diseksiyonu ve pituiter apopleksidir. Bu tanıları karşılamayan hastalara dışlayıcı tanı olarak idiyopatik gök gürültüsü baş ağrısı tanısı konur.[7] RSVS’de serebrovasküler anormallikler geçicidir ve 1–3 ay sonra tekrar edilen görüntülemelerde düzelme tam olarak izlenmektedir. RSVS başlıca primer SSS anjitisini taklit etmektedir. Olgumuzda primer SSS anjitisi BOS bulgularının uyumsuz olması ve kraniyal MRG’de parankim lezyonunun olmaması nedeniyle dışlandı. Literatürde gök gürültüsü baş ağrısı olmaksızın sistemik lupus eritematozus (SLE) tanılı amorozis fugaks ve kolda hafif parazi ile başvuran RSVS tanılı olgu bildirilmiştir.[12] Olgumuzda ise ANA 1/160 titrede pozitif saptanmıştır. Fakat ENA profili ve diğer laboratuar bulgular ile SLE tanısı desteklenmemiştir. Hastamızın ayrıca 3 yıl önce 1.5 ay kadar süren benzer şikayetlerinin olması rekürrensi düşündürmektedir.

[6]

RSVS tedavisinde vazodilatör ajanlar sıklıkla kullanılsa da spesifik bir tedavisi yoktur. Kalsiyum kanal blokörlerinden nimodipin başta olmak üzere, magnezyum ve steroidler de yararları net bilinmemekle birlikte kullanılmaktadırlar. Olgumuzda da nimodipin ve steroid tedavisi başlanmış ve tedaviye yanıt alınmıştır. Özellikle etiyolojide rol oynadığı düşünülen antihistaminiklerin kesilmesi ile baş ağrısında belirgin gerileme izlenmiştir. Balon anjiyoplasti ise sekonder progressif nörolojik defisiti olan hastalarda uygulanmaktadır.[2] NİSAN - APRIL 2017


Antihistaminik kullanımı ile tetiklenen tekrarlayıcı baş ağrısı ve reversible serebral vazokonstriksiyon sendromu

Tekrarlayıcı gök gürültüsü baş ağrısına sahip hastalarda RSVS sendromu ve tetikleyici faktörlerin hızla akla getirilmesi önemlidir. Bu faktörlerin hızlı tedavisi, tetikleyen ilaçların bırakılması morbiditeyi önlemede önemlidir.[8] Nadir görülse de inme gibi mortalite ve morbitiye neden olabilecek komplikasyonlara yol açtığından dolayı RSVS tanısının ve tedavisinin hızla yapılması önemlidir. RSVS sendromunun vurgulanması gereken en önemli özelliğinin benzer klinik prezentasyon gösteren subaraknoid kanama veya primer SSS anjitisinden farklı olarak klinik bulgularının reversibl olmasıdır. RSVS kendini sınırlar fakat genellikle monofazik değildir ve RSVS tanılı hastalarda klinik olarak kötüleşme görülebilir. Literatürde klinik olarak kötüleşme radyolojik infarktın varlığı ve kötü fonksiyonel sonuç ile ilişkilendirilmiştir.[13] Klinik bulgular çoğunlukla düzelmekle birlikte, kalıcı nörolojik defisitler de olabileceği göz önünde bulundurulmalıdır. Hastadan bilgilendirilmiş olur alınmıştır ve yazarlar arasında çıkar ilişkisi yoktur. Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması (conflict of interest) yoktur. Hakem değerlendirmesi: Dış bağımsız.

Kaynaklar 1. Dou YH, Fuh JL, Chen SP, Wang SJ. Reversible cerebral vasoconstriction syndrome after blood transfusion. Headache 2014;54(4):736–44. 2. Ducros A, Boukobza M, Porcher R, Sarov M, Valade D, Bousser MG. The clinical and radiological spectrum of reversible

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cerebral vasoconstriction syndrome. A prospective series of 67 patients. Brain 2007;130(Pt 12):3091–101. 3. Singhal AB, Hajj-Ali RA, Topcuoglu MA, Fok J, Bena J, Yang D, Calabrese LH. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol 2011;68(8):1005–12. 4. Ducros A, Bousser MG. Reversible cerebral vasoconstriction syndrome. Pract Neurol 2009;9(5):256–67. 5. Call GK, Fleming MC, Sealfon S, Levine H, Kistler JP, Fisher CM. Reversible cerebral segmental vasoconstriction. Stroke 1988;19(9):1159–70. 6. Hammad TA, Hajj-Ali RA. Primary angiitis of the central nervous system and reversible cerebral vasoconstriction syndrome. Curr Atheroscler Rep 2013;15(8):346. 7. Sattar A, Manousakis G, Jensen MB. Systematic review of reversible cerebral vasoconstriction syndrome. Expert Rev Cardiovasc Ther 2010;8(10):1417–21. 8. Ducros A. Reversible cerebral vasoconstriction syndrome. [Article in French] Presse Med 2010;39(3):312–22. [Abstract] 9. Ducros A. Reversible cerebral vasoconstriction syndrome. [Article in French] Rev Neurol (Paris) 2010;166(4):365–76. [Abstract] 10. Drazin D, Alexander MJ. Call-fleming syndrome (reversible cerebral artery vasoconstriction) and aneurysm associated with multiple recreational drug use. Case Rep Neurol Med 2013;2013:729162. 11. Nouh A, Ruland S, Schneck MJ, Pasquale D, Biller J. Reversible cerebral vasoconstriction syndrome with multivessel cervical artery dissections and a double aortic arch. J Stroke Cerebrovasc Dis 2014;23(2):141–3. 12. Uenaka T, Hamaguchi H, Sekiguchi K, Kowa H, Kanda F, Toda T. Reversible cerebral vasoconstriction syndrome in a stroke patient with systemic lupus erythematosus and antiphospholipid antibody. [Article in Japanese] Rinsho Shinkeigaku 2013;53(4):283–6. [Abstract] 13. Katz BS, Fugate JE, Ameriso SF, Pujol-Lereis VA, Mandrekar J, Flemming KD, et al. Clinical worsening in reversible cerebral vasoconstriction syndrome. JAMA Neurol 2014;71(1):68–73.

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doi: 10.5505/agri.2016.92053

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LETTER TO THE EDITOR

An unusual complication of anesthesia: Unilateral spinal myoclonus Anestezinin olağandışı bir komplikasyonu: Tek taraflı spinal miyoklonus Bahadır KÖSEM, Hatice KILINÇ

To the Editor, Myoclonus is comprised of sudden, involuntary contractions of a group of muscles, a single muscle, or part of a muscle. Spinal, focal, or segmental myoclonus has specific features that distinguish it from other forms of more generalized myoclonus. It is often restricted to one somatic region due to the pathology at the involved level of the spinal cord. The possible causes are tumor, infection, trauma and degenerative processes.[1] Drugs administered through intrathecal and epidural routes, neuraxial high dose opioid therapy, indwelling spinal or epidural catheters can occasionally cause myoclonus.[2,3] Herein we presented a patient with unilateral spinal myoclonus due to spinal anesthesia. A 36-year-old woman underwent surgery for left leg varices. She had no previous surgeries, no significant medical history, no allergies and no previous neurological disease. She was premedicated with 3 mg midazolam following blood pressure, SpO2 and ECG monitoring. She then received 3 ml of 0.5% hyperbaric bupivacaine given by a 25G spinal needle through the L4-L5 interval on the left side and left fowler position. No opioids were added. A sensory block up to the thoracic 6 level (pin prick technique) associated with motor block was obtained prior to the start of surgery. The surgery proceeded uneventful, as well as the intraoperative course. One hour after surgery, the patient was presented with sudden,

involuntary and unilateral rhytmic contractions of right leg. This movements were not associated with voluntary movements or reflex stimuli, and there was no evidence of weakness, impairment of vibration, pinprick of touch sense, or cerebellar or cranial nevre dysfunction. Conventional brain and spinal cord magnetic resonance imaging (MRI) disclosed no abnormalites. In addition laboratory tests including serum B12, calcium, magnesium and potasium levels were both normal. According to laboratory and clinical investigation spinal myoclonus due to spinal anesthesia was diagnosed. Five hours after surgery, voluntary movement of right leg associated with myoclonus was disappeared. During the course of spinal myoclonus no medication was used. Acute spinal myoclonus following regional anaesthesia is extremely rare, and treatment should be directed at the aetiology. Anaesthetists should watch out for this anaesthetic complication, especially in patients with underlying vitamin deficiency or neuromuscular disease. Anaesthetists who are unfamiliar with this rare complication should be reassured that it may be treated successfully with midazolam.[4] In addition in the literature some authors suggested that patient with spinal myoclonus can be followed up without any treatment.[5] Unilateral spinal myoclonus following regional anaesthesia is extremely rare. In conclusion the clinicians should be kept in mind this unusual complication especially in patient with regional anesthesia.

Department of Anesthesia, Turgut Özal University Faculty of Medicine, Ankara, Turkey Submitted: 04.11.2015 Accepted after revision: 02.06.2016 Available online date: 26.12.2016

Correspondence: Dr. Bahadır Kösem. Turgut Özal Üniversitesi Tıp Fakültesi, Anestezi Anabilim Dalı, Ankara, Turkey. Phone: +90 - 312 - 203 58 62 e-mail: bahadir.kosem@gmail.com © 2017 Turkish Society of Algology

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An unusual complication of anesthesia

References 1. Hoehn MM, Cherington M. Spinal myoclonus. Neurology 1977;27(10):942–6. 2. Alfa JA, Bamgbade OA. Acute myoclonus following spinal anaesthesia. Eur J Anaesthesiol 2008;25(3):256–7. 3. Ford B, Pullman SL, Khandji A, Goodman R. Spinal my-

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oclonus induced by an intrathecal catheter. Mov Disord 1997;12(6):1042–5. 4. Caviness JN, Brown P. Myoclonus: current concepts and recent advances. Lancet Neurol 2004;3(10):598–607. 5. Celik Y, Bekir Demirel C, Karaca S, Kose Y. Transient segmental spinal myoclonus due to spinal anaesthesia with bupivacaine. J Postgrad Med 2003;49(3):286.

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doi: 10.5505/agri.2016.27880

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LETTER TO THE EDITOR

Sonoanatomic variation of the vasculature at infraclavicular region İnfraklavikular bölgede vaskülatürün sonokanatomik varyasyonu Onur BALABAN,1 İlker İTAL,1 Ekrem AYDIN,2 Mehmet KORKMAZ,3 Tayfun AYDIN4

To the Editor, Variations in the arrangement and distribution of brachial plexus and its branches at the infraclavicular region are common and have been reported by several investigators.[1,2] The position of the three cords and veins was found markedly variable with respect to the artery.[2] But these are expected as small branch vessels from the subclavian artery and subclavian vein, which are frequently evident on ultrasound imaging.[3] When performing infraclavicular blocks, the nerves and artery are usually visualized at the deep surface of the pectoralis major and minor muscles. Three bunches of nerve trunk were found cephalic, lateral and posterior to the axillary artery.[4] We report an unusual anatomic variation of vasculature at infraclavicular region. Our case was a 34 years old patient who had a trigger finger at right hand. There was no disease or surgery in his medical history. The Orthopedic Surgery Department planned to perform a release operation. Ultrasound guided infraclavicular block was planned during pre-anesthetic visit for surgical anesthesia. After mild sedation, the ultrasound transducer was placed at the block site. However we experienced a different image than expected (Fig. 1a). There were four vessels under the pectoralis muscles. We slightly

tilted the transducer and the image did not change remarkably. We tried the pressure, alignment and rotation maneuvers of the transducer. One of the vessels which was a vein, disappeared when slight pressure was applied. There was pulsation in one of the vessels which was at the center of the others. In color doppler imaging, the pulsatile vessel was identified as an artery, and the others were veins (Fig. 1b). One of the veins was lateral to the artery, in front of the route of the needle. The size of all veins were similar to each other and seemed as big as the artery. We inserted the needle under ultrasonic control using in plane technique. When the tip of the needle came closer to the vein, we directed the tip distant to the artery. If the needle had been inserted directly, possibly it would puncture the vein. The needle tip was advanced carefully passing from the lateral side of the vein, than directed medially to reach to the posterior side of the artery. 20 mililiters of local anesthetic drug was given at 8 oclock position, next and posterior to the artery. Local anesthetic distrubition was seen as a u shape around and posterior of the artery resulting a successful block without any complications (Fig. 1c). The block area was examined by a radiologist from Radiology department after the operation. We concluded that the vessels are in an unusual arrangement in this case. In a cadaver case, tributaries of axillary vein were found forming venous circle deep to the pectoral muscles, in the infraclavicular region.[5] To our knowledge, a big accessory vein placed in the

Department of Anesthesiology and Reanimation, Dumlupınar University Faculty of Medicine, Kütahya, Turkey Department of Orthopedic Surgery, Dumlupınar University Faculty of Medicine, Kütahya, Turkey 3 Department of Radiology, Dumlupınar University Faculty of Medicine, Kütahya, Turkey 4 Department of Pain, Dumlupınar University Faculty of Medicine, Kütahya, Turkey 1 2

Submitted: 18.12.2015 Accepted after revision: 02.06.2016 Available online date: 26.12.2016

Correspondence: Dr. Onur Balaban. Dumlupınar Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Kütahya, Turkey. Phone: +90 - 274 - 231 66 60 e-mail: obalabandr@gmail.com © 2017 Turkish Society of Algology

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Sonoanatomic variation of the vasculature at infraclavicular region (a)

(b)

(c)

Figure 1. (a) Ultrsonographic view of the vasculature at infraclavicular region. (b) Color doppler image of the vasculature. (c) Needle tip and local anesthetic distribution around the axillary artery.

pathway of the needle regarding an infraclavicular block, was not reported before. In regard to this case, we would like to reinforce the importance of ultrasound guidance in preventing injuries to vessels from the needle and also the avoidance of local anesthetic toxicity in brachial plexus blocks in which a highly anatomic variability is evident.

2.

3.

4.

References 1. van Geffen GJ, Moayeri N, Bruhn J, Scheffer GJ, Chan VW, Groen GJ. Correlation between ultrasound imaging, crosssectional anatomy, and histology of the brachial plexus: a

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5.

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