Prevalence of Rheumatoid Arthritis and Spondyloarthritis in Turkey: A Nationwide Study.

OBJECTIVES: This study aims to estimate the prevalence of rheumatoid arthritis (RA) and spondyloarthritis (SpA) in Turkey using the same telephone questionnaire developed for screening RA and SpA in France and used in Serbia and Lithuania. MATERIAL AND METHODS: The study was performed in two steps. In step I, the French questionnaire was translated into Turkish and validated through a group of 200 patients (80 males, 120 females; mean age 44.0±13.1 years; range 19 to 75 years) followed up at the rheumatology departments of University Hospitals in Antalya and Ankara. In step II, the validated Turkish questionnaire was administered face-to-face to randomly selected 4,012 subjects (1,670 males, 2,342 females; mean age 41.5±16.8 years; range 16 to 97 years) by trained general practitioners across the country, in 25 prov- inces for case detection. The subjects who were suspected of having RA or SpA in accordance with the questionnaire were invited to the nearest university hospital for rheumatologic examination in order to confirm the diagnosis. RESULTS: In step II, a total of 25 subjects (2 males, 23 females) were diagnosed as RA. The standardized RA prevalence for the general population of Turkey was calculated as 0.56% (95% confidence interval [CI]; 0.33-0.79), 0.10% (95% CI; -0.05-0.25) for males and 0.89% (95% CI; 0.51-1.27) for females. A total of 18 subjects (3 males, 15 females) were diagnosed as SpA. The standardized SpA prevalence for the general population of Turkey was 0.46% (95% CI; 0.25-0.67), 0.17% (95% CI; -0.03-0.37) for males and 0.65% (95% CI; 0.32-0.98) for females. The prevalence of RA was highest in the Northern region (2.00%) and the prevalence of SpA was highest in the Central region (1.49%). CONCLUSION: The prevalences of RA and SpA in Turkey are close to each other and there are significant inter-regional variations in prevalences of both RA and SpA.

2017 update of the Turkish League Against Rheumatism (TLAR) evidence-based recommendations for the management of knee osteoarthritis.

In a Turkish League Against Rheumatism (TLAR) project, evidence-based recommendations for the management of knee osteoarthritis (OA) was developed for the first time in our country in 2012 (TLAR-2012). In accordance with developing medical knowledge and scientific evidence, recommendations were updated. The committee was composed of 22 physical medicine and rehabilitation specialists (4 have rheumatology subspeciality also) and an orthopaedic surgeon. Systematic literature search were applied on Pubmed, Embase, Cochrane and Turkish Medical Index for the dates between January the 1st 2012 and January the 29th of 2015. The articles were assessed for quality and classified according to hierarchy for the level of evidence, and the selected ones sent to committee members electronically. They were asked to develop new recommendations. In the meeting in 2015, the format of the recommendations was decided to be patient-based and considering the grade and the severity of the disease. By the discussion of the each item under the light of new evidences, the final recommendations were developed. Each item was voted electronically on a 10-cm visual analogue scale (VAS) and the strength of recommendation (SoR) was calculated. In the light of evidences, totally 11 titles of recommendations were developed; the first 7 were applicable to each patient in every stages of the disease, remaining were for defined specific clinical situations. The mean SoR value of the recommendations was between 7.44 and 9.93. TLAR-2012 recommendations were updated in a new format. We think that, present recommendations will be beneficial for the physicians who manage, as well as the patients who suffer from the disease.

The utility of faces pain scale in a chronic musculoskeletal pain model.

OBJECTIVES: The main aim of this study was to investigate the clinical utility and sensitivity to change of faces pain scale (FPS) in patients with shoulder pain, chosen as a chronic pain model. The secondary aim was to determine the association of FPS with psychologic status and quality of life of these patients. METHODS: Thirty Turkish patients with chronic shoulder pain were included in the study. Pain intensity was evaluated by visual analog scale (VAS), which is a commonly used pain scale besides FPS. Depression and quality of life were screened by Beck Depression Inventory (BDI) and Short Form-36 (SF-36). All assessments were done before and after the physical therapy. RESULTS: There was a statistically significant decrease in pain severity after the treatment as indicated by FPS and VAS (P=0.000). The standardized response mean (SRM) value of FPS of 2.35 was accepted as a good responsiveness. The FPS showed a strong correlation with VAS (r=0.62 and 0.73) both before and after the treatment. Also, moderate to strong correlations were detected between the FPS and physical functioning (PF), physical role (PR), bodily pain (BP), emotional role (ER), general health (GH), mental health (MH) subscales of SF-36 (r=-0.58-0.80), and BDI scores (r=0.39) before the treatment. However, there were moderate and weak correlations with FPS and PR and social functioning (SF) subscales of SF-36 only after the treatment (r=-0.52 and r=-0.39). CONCLUSIONS: FPS is a satisfactory tool to assess pain in patients with chronic pain conditions and demonstrates sensitivity to detect changes after the treatment.

Reliability, construct validity and measurement potential of the ICF comprehensive core set for osteoarthritis.

BACKGROUND: This study aimed to investigate the reliability and construct validity of the International Classification of Functioning, Disability and Health (ICF) Comprehensive Core Set for osteoarthritis (OA) in order to test its possible use as a measuring tool for functioning. METHODS: 100 patients with OA (84 F, 16 M; mean age 63 yr) completed forms including demographic and clinical information besides the Short Form (36) Health Survey (SF-36®) and the Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC). The ICF Comprehensive Core Set for OA was filled by health professionals. The internal construct validities of "Body Functions-Body structures" (BF-BS), "Activity" (A), "Participation" (P) and "Environmental Factors" (EF) domains were tested by Rasch analysis and reliability by internal consistency and person separation index (PSI). External construct validity was evaluated by correlating the Rasch transformed scores with SF-36 and WOMAC. RESULTS: In each scale, some items showing disordered thresholds were rescored, testlets were created to overcome the problem of local dependency and items that did not fit to the Rasch model were deleted. The internal construct validity of the four scales (BF-BS 16 items, A 8 items, P 7 items, EF 13 items) were good [mean item fit (SD) 0.138 (0.921), 0.216 (1.237), 0.759 (0.986) and -0.079 (2.200); person item fit (SD) -0.147 (0.652), -0.241 (0.894), -0.310 (1.187) and -0.491 (1.173) respectively], indicating a single underlying construct for each scale. The scales were free of differential item functioning (DIF) for age, gender, years of education and duration of disease. Reliabilities of the BF-BS, A, P, and EF scales were good with Cronbach's alphas of 0.79, 0.86, 0.88, and 0.83 and PSI's of 0.76, 0.86, 0.87, and 0.71, respectively. Rasch scores of BF-BS, A, and P showed moderate correlations with SF-36 and WOMAC scores where the EF had significant but weak correlations only with SF36-Social Functioning and SF36-Mental Health. CONCLUSION: Since the four different scales derived from BF-BS, A, P, and EF components of the ICF core set for OA were shown to be valid and reliable through a combination of Rasch analysis and classical psychometric methods, these might be used as clinical assessment tools.

Is there an association between mastalgia and fibromyalgia? Comparing prevalence and symptom severity.

To determine the prevalence of mastalgia in patients with fibromyalgia (FM) and the prevalence of FM in patients with mastalgia in order to investigate coexistence, and to compare the pain patterns in the case of mastalgia or FM alone versus the two in combination. Fifty consecutive patients with mastalgia and 50 consecutive patients with FM were assessed and examined both for the existence and severity of mastalgia and FM. A high proportion of patients with mastalgia (36%) fulfilled the criteria for FM and 42% had mastalgia in the FM group. Two distinctive entities mastalgia and FM, being both unexplained pain syndromes, seem to frequently coexist. Patients with mastalgia or FM should be thoroughly questioned considering each of the diseases so that in case of coexistence an appropriate therapy might be implemented for a successful pain management.

Psychometric properties of the Rivermead Motor Assessment: its utility in stroke.

OBJECTIVE: To investigate the psychometric properties of the Rivermead Motor Assessment by Rasch analysis and conventional statistics to improve its clinical utility. METHODS: A total of 107 patients after stroke were evaluated using the Rivermead Motor Assessment and Functional Independence Measure (FIM). Scaling properties were assessed using Mokken scaling, internal construct validity using Rasch analysis, reliability using Cronbach's alpha and intra-class correlation coefficients, external construct validity through convergent validity with FIM, and responsiveness using the effect size and standardized response mean. RESULTS: Cronbach's alpha and intra-class correlation coefficients for 3 sections of the Rivermead Motor Assessment were between 0.88 and 0.95. Mokken scaling showed appropriate Guttman patterns, but the hierarchical ordering of the items differed from that of the original. After removing 4 items of gross function, 1 of leg-trunk, and 4 of arm, all sections met Rasch model expectations. External construct validity was confirmed. Mean values of effect size and standardized response were 0.38-0.51 and 0.60-0.89, respectively. CONCLUSION: The Rivermead Motor Assessment has been shown to be reliable and responsive. Guttman scaling is apparent, but not as originally defined. After removing some items, the scale satisfies the most stringent Rasch measurement criteria and can produce interval scaling for the assessment of motor function in stroke.

Adaptation of the Shoulder Disability Questionnaire to the Turkish population, its reliability and validity.

The objective of this study was to adapt the Shoulder Disability Questionnaire (SDQ) for use in Turkey, and to test its reliability and validity. Eighty patients with shoulder pain were included in the study. Pain severity at rest, with motion and during sleeping was assessed by using a numeric pain scale. The shoulder's active and passive range of motion were measured by a goniometer and recorded. The Constant-Murley scale was used for functional assessment. The Turkish version of the SDQ, which was adapted by using guidelines, was completed by the patients. To assess reproducibility, the SDQ was completed by 32 patients who did not improve 1 week later. The reliability of the adapted version was good, with high internal consistency (Cronbach's alpha=0.76) and test-retest reliability (Pearson's correlation coefficient=0.88). The Turkish version of the SDQ was found to have a moderate correlation with pain at rest, with motion and during sleeping. The Turkish version of the SDQ was found to be reliable and valid. The moderate correlation of the questionnaire with clinical parameters including pain shows its validity, but the questionnaire should be tested extensively for detecting changes within time, for use in the follow-up and clinical practice.

Does treadmill training improve lower-extremity tasks in Parkinson disease? A randomized controlled trial.

OBJECTIVE: To investigate whether gait training with treadmill improves functional tasks of lower extremities in patients with Parkinson disease (PD). DESIGN: Randomized controlled trial including two groups, the treadmill training group and the nonintervention group. SETTING: University hospital. PATIENTS: Thirty consecutive patients diagnosed with idiopathic PD, who were on stable regimens of antiparkinsonian medication, able to walk independently, and had not participated in a rehabilitation program in the previous 3 months. Patients with severe cognitive impairments or severe musculoskeletal, cardiopulmonary, neurologic, or other systemic disorders were excluded. Twenty-four patients completed the study. INTERVENTIONS: Group I attended a training program on a treadmill for 6 weeks, and group II served as the control group. Both groups were instructed in home mobility exercises. MAIN OUTCOME MEASUREMENTS: The primary study outcome measures were timed functional lower-extremity tasks (walking at a corridor, U-turn, turning around a chair, stairs, standing on one foot, standing from a chair), and secondary outcome measures were exercise test and patient's global assessment. Assessments were performed at baseline and at the end of the study. RESULTS: There were significant improvements in functional lower-extremity tests, exercise test parameters, and patients' global assessment in group I, whereas no significant improvements were observed in group II. CONCLUSIONS: Even though long-term effects remain unknown and the study sample was small, it was concluded that treadmill training in PD patients led to improvements in lower-extremity tasks, thus improving patients' physical well-being in daily life.

Comparison of three different approaches in the treatment of chronic low back pain.

Our aim is to investigate the effects of three therapeutic approaches in the chronic low back pain on pain, spinal mobility, disability, psychological state, and aerobic capacity. Sixty patients with chronic low back pain were randomized to three groups: group 1, aerobic exercise + home exercise; group 2, physical therapy (hot pack, ultrasound, TENS) + home exercise; group 3, home exercise only. Spinal mobility, pain severity, disability, and psychological disturbance of the patients were assessed before and after the treatment and at 1-month follow-up. Aerobic capacities of the patients were measured before and after treatment. All of the groups showed similar decrease in pain after the treatment and at 1-month follow-up, and there was no significant difference between the groups. In group 2, a significant decrease in Beck Depression Inventory scores was observed with treatment. At 1-month follow-up, group 1 and 2 showed significant decreases in General Health Assessment Questionnaire scores. In group 2, there was also a significant improvement in Roland Morris Disability scores. There were similar improvements in exercise test duration and the MET levels in all the three groups. All of the three therapeutic approaches were found to be effective in diminishing pain and thus increasing aerobic capacity in patients with chronic low back pain. On the other hand, physical therapy + home exercise was found to be more effective regarding disability and psychological disturbance.

Efficacy of a home-based exercise program on benign paroxysmal positional vertigo compared with betahistine.

OBJECTIVE: To determine the efficacy of a home-based exercise program by comparing it with betahistine in patients with benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Prospective, randomized, controlled study. SETTING: Outpatient clinic of a university hospital. PATIENTS: Thirty-eight patients (10 males, 28 females; mean age 46 +/- 13 years) diagnosed as having BPPV. INTERVENTIONS: Patients were randomly assigned to either an exercise or a medication group. In the medication group, betahistine was prescribed at 24 mg/d for 1 month. The exercise group was required to perform Cawthorne-Cooksey exercises six times/day for 4 weeks. MAIN OUTCOME MEASURES: The Vertigo, Dizziness, Imbalance Questionnaire (VDI), which consists of two subscales, the VDI symptom subscale (VDI-ss) and the VDI health-related quality of life (VDI-HRQoL) subscale, and the Vertigo Symptom Scale (VSS) were used for assessment at the beginning of the study and after 2 months. RESULTS: The mean scores of the two components of the VDI and the VSS decreased in the exercise group by the fourth week. In the medication group, VSI mean scores, VDIss mean scores, and VSS mean scores decreased in the second week and VDI-HRQoL mean scores decreased in the fourth week. However, there were no significant differences between baseline and week 8. There were significant differences between groups regarding the change in the mean scores of the VDI (p = .001) and the VSS (p = .001) at the end of the study in favour of the exercise group. CONCLUSIONS: Exercise was found to be a better treatment choice than medication and may be preferable for patients with persistent or chronic vertigo.

The reliability and validity of the Vertigo Symptom Scale and the Vertigo Dizziness Imbalance Questionnaires in a Turkish patient population with benign paroxysmal positional vertigo.

The aim of this study was to adapt the Vertigo Symptom Scale (VSS) and the Vertigo Dizziness Imbalance (VDI) Questionnaires to the Turkish population and investigate the reliability and validity of the Turkish version. One hundred and three patients with Benign Paroxysmal Positional Vertigo (BPPV) were included in the study. The patients were evaluated with the VSS and the VDI twice, at recruitment and 24 hours later. To perform concurrent validity study study, patients were also assessed by the Beck Depression Inventory (BDI) and the Medical Outcomes Survey Short Form 36 (SF-36) which were formerly proved to be valid and reliable for use in Turkish population. The internal consistency of the VSS, VDI-symptom scale, and VDI-health-related quality of life scale were good with Cronbach's alpha of 0.91, 0.85, and 0.93 respectively which showed high reliability for the Turkish versions. Test-retest reliability was also good, with a high intraclass correlation coefficient (ICC) between the two time points; being 0.83 for the VSS, 0.90 for the VDI-symptom scale and 0.89 for the VDI-health related quality of life scale. Regarding concurrent validity, significant expected correlations were detected between the VSS and BDI (r = 0.55 p < 0.001) and the VSS and SF-36 (r = -0.43 p < 0.001). Significant low correlations were detected between the VDI-SS and BDI (r = 0.20 p < 0.05) and the VDI-SS and SF-36 (r = -0.21 p < 0.05). High correlations were observed between the VDI-HRQoL and BDI (r = -0.75 p < 0.001) and the VDI-HRQoL and SF-36 (r = 0.82, p < 0.001) which indicates high concurrent validity. The correlation between VDI-SS subscale scores and VDI-HRQoL subscale scores were 0.028 (P = 0.778) at the first time point. From the perspective of discriminant validity, it means that the VDI-SS measures a construct different from the one underlying the VDI-HRQoL. The adaptation of the VSS and VDI to the Turkish population was successful and both scales were found to be valid and reliable. Thus, they can be used in Turkish people with BPPV for assessment and monitoring the treatments. Besides, the results of the national studies in which these Turkish versions are used can be compared with those of the international studies.

Hypothalamic-pituitary-adrenal hormonal responses to exercise stress test in patients with rheumatoid arthritis compared to healthy controls.

OBJECTIVE: There is controversy about hormonal dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis that is supposed to contribute to the development or persistence of rheumatoid arthritis (RA). We investigated whether there is an altered and blunted response of the HPA axis when stimulated by exercise stress in patients with RA. METHODS: Twenty women with RA and 15 matched healthy controls were included in the study. All subjects took an ergospirometric exercise test on the treadmill to determine anaerobic threshold (AT). On another day, blood was collected for basal plasma levels of growth hormone (GH), insulin-like growth factor-I, cortisol, and adrenocorticotrophic hormone (ACTH); and subjects exercised on treadmill at an intensity above their AT. Blood was collected again to measure hormone levels just after the exercise stopped and 60 minutes later. RESULTS: Two subjects left the study, so 19 patients and 14 controls were evaluated. Peak oxygen consumption (VO(2)), VO(2) at AT, exercise test duration, and basal hormone levels were similar in groups. In both groups, GH slightly increased just after the exercise (0 min), and decreased at 60 min compared to baseline, but the change was not different between groups. Cortisol levels decreased significantly at 0 and 60 min in both groups, ACTH levels did not change in time, and there was no difference between groups. CONCLUSION: There was no perturbation in HPA axis stimulated by exercise stress test in patients with RA and all the variables measured were similar to those of the control group.

Exercise and cognitive-behavioural treatment in fibromyalgia syndrome.

Fibromyalgia syndrome is a nonarticular rheumatic disorder characterised by diffuse musculoskeletal pain, stiffness, fatigue, disturbed sleep and tender points. The pathophysiology is not well understood and treatment remains a challenge. Although pharmacological therapy is still the primary treatment choice, a long-term effective intervention has not been demonstrated yet. Thus, besides pharmacotherapy, other multimodal interventions are often used. Exercise and cognitive-behavioural treatments which exist in the multimodal approach and encompass largely self-managed strategy, are reviewed in this article. Although, there is a great number of exercise studies, the large diversity of outcome measures and measurement instruments that have been used in studies, varying intensity and types of exercises, small sample sizes, high attrition rates, large variability in baseline function, symptom severity and psychosocial status limit to come to a conclusion about the efficacy of exercise in the treatment of fibromyalgia syndrome. There are also inconclusive results about the efficacy of cognitive-behavioural treatment because of limited number of studies with small sample sizes of patients with fibromyalgia syndrome. However, the results of the trials overall demonstrate the beneficial effects of both different types of exercise and cognitive-behavioural treatment, on the other hand, there is still a need for larger, more systematic and randomised controlled trials to evaluate the effectiveness.