Stretching exercises for costochondritis pain.

The term costochondritis (ChC) indicates a painful and persistent inflammation at the costochondral or costosternal junction. The usual conservative treatment (NSAIDs), local splinting, local heat) and sometimes disappointing. The aim of this study is to evaluate the effect of stretching exercises in a group of patients affected with ChC. This retrospective open study involved 51 outpatients with diagnosis of ChC: thirty four consecutive patients were treated with stretching exercises, 34 patients matched for age, pain and disease duration constituted the control group. All the patients had spontaneous pain at least in the one of the costochondral junctions at the third to seventh rib. The intensity of spontaneous pain was measured by means of the visual analogic scale of Scott-Huskisson. The homogeneity of the two groups at the beginning of the study was checked for VAS, for disease duration and age by means of Mann-Whitney test for non-parametric measures. The statistical analysis of pain was done by Friedman analysis of variance and Student-Newman-Keuls multiple comparisons tests. The results showed a progressive significant amelioration in patients treated with stretching exercises as respect as the control group (p<0.001). The goal of therapy of costochondritis is to reduce inflammation and the pain. The NSAIDs, local injection of anaesthetic or steroid has insufficient effectiveness. The possibility to improve the pain by means of simple stretching exercises can supply a useful instrument in order to treat the condition of these patients.

Sonographic assessment of soft tissue alterations in osteoarthritis of the knee.

Osteoarthritis (OA) is the most common joint disorder to affect the knee, and the single most important cause of disability in aged elderly people. Radiological criteria for knee OA (focal loss of cartilage, osteophytosis, subchondral cysts and subchondral sclerosis) reflect late manifestations and significant joint damage only. Ultrasound examination is useful in revealing disruption of the periarticular tissue that contributes to symptoms and disability in advanced disease. Nevertheless, ultrasound examination is very important in early OA of the knee when it can give information about soft tissues and cartilage involvement also in absence of clinical symptoms.

HLA-DRB1alleles and osteoarthritis in a group of patients living in Liguria-Italy.

AIM: Osteoarthritis (OA), a degenerative arthro-pathy, produces damage and cartilage loss in one or more joints. Genetic factors contribute substantially to the risk of OA. The nature of the genetic influence in OA is speculative and may involve both a structural defect (i.e. collagen), alterations in cartilage or bone metabolism. Analyses of the frequencies of HLA antigens in various OA populations showed different RESULTS: The aim of this study was to verify the prevalence of HLA-DRB1 haplotypes in 92 outpatients of the Rheumatological Center of Genoa University. METHODS: Ninety-two outpatients (69 females, 23 males) affected by OA were enrolled and divided into a group with OA of the hands and a group with different joints localizations. Both groups have been compared with a control group, represented by 150 Italian marrow donors, to detect a typology of second class HLA alleles that, if present, may represent a risk factor of disease. The statistical significance between the groups were assessed by means of the contingency table to compare frequencies (P<0.05 was considered as significant). RESULTS: The results obtained showed that the frequency of DRB1*12 and *10 alleles families, not present in the second study group, has been compared only between the first study group and the control group. Haplotypes *07 e *04 are more frequent in the second group than in the first group and in the control group and haplotype *13 is the most represented in the first and second group. Haplotypes *11 and *13 are more significantly represented in the control group. CONCLUSIONS: The results obtained with the study of HLA-DRB1 locus in patients affected by OA and living in Liguria may suggest a research on a larger number of OA patients to confirm the data obtained in this study and to define DRB1 haplotypes as more frequent markers both in OA of the hand and in OA of other joints.

Hyperechoic plaque: an ultrasound marker for osteoporosis in acute stroke patients with carotid disease.

BACKGROUND: Osteoporosis is a significant complication of stroke, and hip fracture after a stroke is a frequent problem. Moreover, growing evidence links vascular and bone diseases, in the form of osteoporosis associated with both atherosclerosis and vascular calcification. The aim of our study is to detect bone change in the acute phase of ischemic stroke in patients with carotid disease and to verify the correlation with carotid echogenic plaques. PATIENTS AND METHOD: Out of 245 subjects consecutively admitted to our Stroke Unit for their first ischemic stroke, we selected 49 patients with a first-ever stroke due to carotid atherosclerosis without a previous diagnosis of bone disease. We assessed risk factors for cerebrovascular disease as well as for osteoporosis, the degree of neurological deficit and disability, and bone mineral density that was quantified by bilateral hip dual energy X-ray absorbimetry. Osteoporosis was defined as a T score below -2.5. Carotid ultrasound was used to classify plaques in non-hyperechoic (grade 1) and hyperechoic plaque (grade 2). RESULTS: We found a high prevalence of low bone mass density (BMD) in our patients (18 out of 49=36.7%), without relationship to the side of paresis. According to univariate analysis evidence of osteoporosis was correlated with age (p=0.05), score of Scandinavian Stroke Scale (p=0.01) and grade 2 plaque (p=0.01). According to multivariate analysis, there was a significant positive correlation between grade 2 plaques and osteoporosis (OR=6.58; 95% CI=1.57-27.54; p=0.01), which was stronger in women (OR=18.15; 95% CI=1.80-182.83; p=0.01). The percentage of intraplaque hyperechogenicity was inversely correlated with BMD (r=-0.411, p=0.016). CONCLUSION: Osteoporosis is highly prevalent in acute atherosclerotic stroke patients. Carotid hyperechoic plaque is an independent marker of osteoporosis.

Prevalence of DRB1*01 and DRB1*04 alleles in a group of patients with rheumatoid arthritis living in Liguria.

A major component of genetic susceptibility to rheumatoid arthritis (RA) appears to be explained by inheritance of HLA-DRB1 alleles. Multiple HLA-DRB1 alleles (DRB1*0401, *0404, *0405, *0408, *0101, *102, *1001 and *1402) encoding a shared epitope at amino acid positions 70-74 are associated with susceptibility to RA. There is ethnic variation in the clinical expression of RA and in both the frequency and type of HLA-DRB1 alleles carrying the shared epitope. We evaluated the prevalence of the alleles of HLA-DRB1 locus encoding for SE in 42 outpatients with RA attending the Rheumatology Center of the University of Genoa, Bruzzone Institute, and living in Liguria. A control group was composed of Italian marrow donors. DNA genotyping was performed using a low-resolution polymerase chain reaction technique for characterization of the families of HLA-DRB1 alleles for each of the 42 patients studied. Subsequently, subjects with *01 and *04 haplotype were tested with high-resolution HLA-DRB 1 typing to characterize the *01 and *04 alleles. No statistically significant differences were found in the prevalence of RA-associated single alleles *01 and *04 in the study group or in the control group. In contrast, the sum of susceptibility *04 alleles studied by resolution typing was strongly related to RA in the study group in comparison with the control group.

Analgesic efficacy of a lecithin-vehiculated diclofenac epolamine gel in shoulder periarthritis and lateral epicondylitis: a placebo-controlled, multicenter, randomized, double-blind clinical trial.

Diclofenac epolamine (2-hydroxyethyl-pyrrolidine) (DHEP) is a diclofenac salt endowed with enhanced cutaneous permeation. To optimize its absorption after topical application, a lecithin-enriched DHEP 1.3% gel has been developed (DHEP lecithin gel) and investigated in patients with shoulder periarthritis and lateral epicondylitis in a placebo-controlled, multicenter double-blind clinical trial. One hundred fifty-eight patients were randomized to a 10-day treatment with DHEP lecithin gel or placebo (5 g t.i.d. applied on the painful area). The efficacy criteria were pain measured by visual analog scale (VAS) while performing a specific standardized movement, intake of rescue medication (paracetamol), and the disabilities of the arm, shoulder and hand (DASH) questionnaire. VAS scores indicated a consistently higher analgesic activity of DHEP lecithin gel. At day 3, pain was reduced by -20.1 +/- 20.2 and -9.9 +/- 12.7 mm in the DHEP lecithin gel- and placebo-treated patients, respectively (p < 0.001); at day 6 of treatment, DHEP lecithin gel induced a pain reduction of -33.2 +/- 26.1 mm, while the reduction achieved with placebo was only -21.2 +/- 18.8 mm (p < 0.001). The mean changes in DASH questionnaire indicated that DHEP lecithin gel was more effective than placebo in improving patient well-being and reducing difficulties in performing the activities most severely impaired by rheumatism, while no difference was observed between the two treatments in consumption of rescue medication. In conclusion, these results indicate that DHEP lecithin gel is a topically effective analgesic product in patients with shoulder periarthritis or lateral epicondylitis and provide further evidence on the use of topical nonsteroidal anti-inflammatory drugs as an optimal approach to the treatment of localized musculoskeletal disorders.

Very low level laser therapy attenuates edema and pain in experimental models.

In this study, we tested a new square wave microprocessor-controlled red laser with an extremely low peak power output (<3 mW; very low level laser therapy [vLLLT]) in experimental pain in the rat. Acute inflammation was induced by intraplantar injection of carrageenan, chronic inflammation was induced by complete Freund's adjuvant (CFA) and neuropathic pain was produced by sciatic nerve chronic constriction injury (CCI). In our study vLLLT was effective in reducing edema and hyperalgesia in acute and chronic inflammation if administered at the points usually selected for acupuncture. Moreover, spontaneous pain and thermal hyperalgesia were reduced in CCI rats treated with vLLLT In conclusion, vLLLT reduced edema and induced analgesia in experimental plantar pain in rats. We interpret this to mean that enkephalin mRNA level was strongly upregulated in the external layers of the dorsal horn of the spinal cord in CFA and CCI animals, and that vLLLT further increased the mRNA level in single neurons.

Joint involvement patterns in nodal versus erosive osteoarthritis of the hands.

The aim of this study was to evaluate the joint count for affected joints and involvement distribution in erosive osteoarthritis (EOA) versus nodal osteoarthritis (NOA) of the hands in patients matched for sex, age, and disease duration. After recruitment of 101 consecutive outpatients affected with EOA, 101 patients affected by NOA were selected and matched for age, sex, and disease duration. Joint count for distal interphalangeal (DIP), proximal interphalangeal (PIP), and first carpo-metacarpal (CMC-1) joints, presenting Kellgren and Lawrence grade 2-4 OA, was performed. In our study, the number of affected joints was higher in NOA, with significant differences for some articular districts, especially in PIP joints of the fourth finger, and DIP joints of the second, third and fourth fingers.

A two-year study of chondroitin sulfate in erosive osteoarthritis of the hands: behavior of erosions, osteophytes, pain and hand dysfunction.

The aim of this study was to evaluate the effect of 800 mg/die of chondroitin sulfate (CHS) per os plus naproxen versus naproxen over 2 years in patients with erosive osteoarthritis (EOA) of the hands. Joint count for erosions, Heberden and Bouchard nodes, Dreiser's algofunctional index and physicians' and patients' global assessment of disease activity were studied. A total of 24 consecutive patients (22 women and 2 men, mean age 53.0 +/- 6) suffering from symptomatic OA with radiographic characteristics of EOA were evaluated. The patients were divided into two groups of 12 patients each. The first group took naproxen 500 mg only. The second group was treated with CHS 800 mg orally plus naproxen 500 mg. Joint counts, radiological hand examinations and assessment of disease activity were performed at baseline, at 12 months and at 24 months. In the second year the treated group showed significant worsening in erosion, Heberden, Bouchard and Dreiser scores was recorded. Physician and patient global assessments of disease activity showed no significant difference from baseline scores. The untreated group showed significant worsening in erosion, Heberden and Bouchard nodes, Dreiser index and physician and patient global assessment scores. This study confirms the partial efficacy of oral CHS in improving some aspects of EOA.

Prevalence of HFE and TFR2 gene mutation in 118 Ligurian rheumatic patients.

AIM: HFE gene is associated to haemochromatosis, an inherited autosomal recessive disorder responsible of an overload of iron in intestine, liver, pancreas, heart, cutis and joints. Articular and periarticular calcifications may occur. H63D mutation may play a role in the pathogenesis of rheumatoid arthritis. METHODS: DNA of 118 consecutive patients (28 males, 90 females, mean age 58.5+/-13.44) living in Liguria and affected by different rheumatic diseases was examined to evaluate the presence of HFE mutations. RESULTS: Analysis data showed that in 45% (53/118) of patients almost one mutation of HFE gene was present and the presence of H63D mutation in the rheumatic patients was particularly elevated. Data obtained in this study have permitted to reveal that 25 patients of 53 (47.1%) with 1 of 11 HFE mutations suffered from symptomatic or silent chondrocalcinosis. CONCLUSIONS: The conclusion is drawn that this mutation may be correlated to various rheumatic diseases.

Hematic levels of type I collagen C-telopeptide in erosive versus nonerosive osteoarthritis of the hands.

C-telopeptide of type I collagen (CTX I) is considered to be a specific marker sensitive to bone resorption; conversely, type II collagen C-telopeptide (CTX II) is considered to be a useful cartilage marker. CTX I assays in serum and urine samples of patients with various metabolic bone disorders, such as osteoporosis and Paget's disease, have been reported to show increased levels of this collagen fragment. In patients with knee osteoarthritis, a decrease in CTX I and an increase in CTX II were found. Osteoarthritis of the hands is one of the most common forms of osteoarthritis. Erosive osteoarthritis of the hands is a variant entity in which, as a consequence of rapid chondrolysis, bone involvement occurs very early in the process. The aim of this cross-sectional study was to compare CTX I assays in patients with erosive osteoarthritis of the hands versus those with nonerosive osteoarthritis of the hands. From a group of over 200 patients fulfilling the American College of Rheumatology's criteria for hand osteoarthritis, we considered the first 21 consecutive postmenopausal women with hand nodal osteoarthritis and disease duration of > or = 5 years and the first 21 consecutive postmenopausal women additionally presenting central joint erosions and disease duration of > or = 5 years. Our results show that in patients with erosive osteoarthritis, CTX I values are much higher than those in patients with nonerosive osteoarthritis.

Efficacy of disodium-clodronate in the management of joint pain in rheumatoid arthritis. Six months open study.

AIM: The aim of the study was to evaluate the effect on the articular pain of 100 mg of disodium-clodronate administered for 6 days a week by intramuscular injection in rheumatoid arthritis (RA) patients. METHODS: We studied 46 patients (38 females and 8 males middle age 57+/-6.2 years, range from 30 to 80 years) with established RA, in the II and III anatomical stage according to Steinbrocker. Therapeutic regimen was for all patients oral methotrexate 7.5 mg weekly, prednisone 7.5 mg/day and AINS. All of these patients also received disodium-clodronate 100 mg for 6 days a week for 6 months. The results of the VAS for pain, the patient global assessment and the physician global assessment on disease activity have been recorded at baseline, at the 2 months and at 6 months of therapy. RESULTS: VAS for pain and patient global assessment of disease activity values decreased significantly after 2 months of therapy (p<0.01) and in comparing basal versus final observation, but they did not change significantly from month 2 to month 6. The score of physician global assessment on disease activity was found to be significantly improved comparing the basal versus 2 months observation, and 2 months versus 6 months observations (p<0.01). CONCLUSION: Disodium-clodronate may be considered an adjunctive therapy in the pain management of RA patients.

Evaluating pain in osteoarthritis of the hands: the effect of patient information.

The evaluation of osteoarthritis pain is principally based on a subjective rating scale. Accuracy in recording pain score is obviously important. In the present study we evaluated the effect of better standardization of information given to patients in determining the visual analog scale (VAS) score. Fifty-three consecutive male and female outpatients aged 18-65 years (40 women and 13 men) fulfilling the criteria for osteoarthritis of the hands were included in the study. Eligible patients attended the Rheumatology Center on three occasions: day 1, day 3 and day 6 of the study. Two information cards were prepared. On the first card, given to the patient at the end of the first visit, osteoarthritis of the hands was described as a less dangerous disease than rheumatoid arthritis. On the second card, given to patients at the end of the second visit, greater emphasis was placed on anatomo-pathological description of the destructive lesions. VAS score was recorded on days 1, 3 and 6 of observation. ANOVA for repeated measures demonstrated a significant reduction of VAS score between the first and the second assessment and a significant increase between the second and the third assessment. A further significant difference was found in the comparison between the first and third assessment. These results show that different standards of information given to patients may modify VAS score.

Low-power laser in osteoarthritis of the cervical spine.

Patients with symptomatic osteoarthritis of the cervical spine were treated with very low-power modulated laser (LPL). Two applications were performed at an interval of 20 days. Changes in pain and ultrasound thickness of the soft connective tissue layer above the right and the left superior trapezium were studied. No worsening of pain was observed. Pain improved after the first application of LPL in 9 out of 14 patients, but the difference was not significant. Pain improvement remained stable between the first assessment and the second assessment, which was performed after 20 days. In comparison with the first application, at the second application the number of patients with improved pain after LPL increased to 12 out of 14 (p < 0.01). An appreciable difference in the thickness of the subcutaneous soft tissue layer overlying the two superior trapezia was demonstrated in all patients at the first examination. Comparison of the measurements before and after the application of LPL showed significant differences.

Changes in size of periarthritis calcifications in patients with painful shoulder treated with injectable disodium-clodronate.

Calcific periarticular disease is characterized by the deposition of calcium phosphate crystals in many tendons and particularly in the rotator cuff tendons. Calcifications of any size may be accompanied by painful shoulder syndrome and tendon tears. Ecographic assessment of changes in the size of calcifications may be a marker of tissue changes in evolving shoulder periarthropathies. The aim of this study was to compare variations in pain and ultrasound dimensions in the calcifications in the tendons of the rotator cuff in patients treated with disodium-clodronate compared with those treated with paracetamol and nimesulide. In all groups, pain reduction occurred over a 6-month period, but was significantly greater in patients administered disodium-clodronate than in those administered nimesulide or paracetamol. A significant reduction in the size of calcifications was also observed in all three groups, but this reduction was more marked in the disodium-clodronate group.

Chondroitin sulfate in erosive osteoarthritis of the hands.

The aim of this study was to evaluate the joint count for erosions in patients with erosive osteoarthritis (EOA) of the hands treated with 800 mg/day of orally administered chondroitin sulfate plus naproxen, compared with that of patients administered naproxen only. Twenty-four consecutive patients (22 women and two men, mean age 53.0 +/- 6) suffering from symptomatic OA and with radiographic characteristics of EOA were studied. The patients were divided into two groups of 12 patients each. The first group took naproxen 500 mg/day only. The second group was treated with chondroitin sulfate 800 mg/day orally plus naproxen 500 mg/day. Radiological hand examinations were performed at baseline and again after 12 and 24 months. In both groups, the joint count for erosions showed a general tendency to increase over time. Progression of erosions at 24 months was lower in patients treated with 800 mg/day chondroitin sulfate plus naproxen than in patients taking naproxen only (p <0.05). Chondroitin sulfate failed to stop the usual time-associated progression in the number of finger joints presenting erosions in EOA of the hands. It was, however, associated with a lower increase in the number of finger joints with erosions detected after 2 years of radiological observation.

Prevalence of C282Y mutation in patients with rheumatoid arthritis and spondylarthritis.

Rheumatoid arthritis is an inflammatory joint and systemic disease believed to be of autoimmune origin. Predisposing factors also include genetic factors, such as the presence of alleles HLA-DRB1 *04, (HLA-DRB1 *0401, *0404, *0405 and *0408) and, in other ethnic groups, of subtypes DRB1 *0101, *0102 and DRB1 *1001. These genetic factors are believed to raise the risk of developing the disease. In rheumatoid arthritis, as in other chronic inflammatory diseases, iron metabolism dysfunction has been observed and attributed to inflammation. In hereditary hemochromatosis, tissue sideropexia is associated with a peculiar form of arthropathy. C282Y is a point mutation involving the replacement of a cysteine with a tyrosine at position 282 of the HFE protein. When found in homozygosis, there is a close association with hereditary hemochromatosis, accounting for one of the causes of iron metabolism dysfunction observed in this disease. The aim of this study was to compare the frequency of C282Y in patients with rheumatoid arthritis with that in patients with different forms of spondylarthritis and to correlate these findings with iron metabolism parameters. In the group of patients with rheumatoid arthritis, 2/24 (8.34%) were found to be positive for the C282Y mutation in the case of heterozygosis compared with 3/24 (12.5%) of patients with spondylarthritis. In patients with the C282Y mutation, ferritin levels were significantly higher than those in controls; conversely, serum iron levels were higher in patients with spondylarthritis. Serum transferrin levels, although slightly higher in rheumatoid arthritis patients, showed no statistically significant differences.

[Parenteral disodium-clodronate in patients with rheumatoid arthritis. A two-month open clinical study]. / Disodio-clodronato parenterale nel paziente con artrite reumatoide. Studio clinico aperto a due mesi.

BACKGROUND: The aim of the study was to evaluate the effect on articular pain of 100 mg of disodium-clodronate administered daily by intramuscular injection in patients affected by rheumatoid arthritis. METHODS: We studied 24 patients with established rheumatoid arthritis, in the II and III stage according to Steinbrocker. Visual analogue pain scale, physician global assessment activity and patient global assessment activity were recorded at baseline, after 30 days and after 60 days of treatment. RESULTS: VAS significant improvement after 30 days was found. The physician and patient global assessment activity were improved after 60 days of treatment. CONCLUSIONS: Disodium-clodronate given by intramuscular injection at the dose of 100 mg/die in rheumatoid patients vas effective in relieving joint pain during a two-month observation.

Early-morning administration of dexketoprofen-trometamol in morning stiffness induced by nodal osteoarthritis of the hands.

Morning stiffness in osteoarthritis (OA) of the hands is a troublesome symptom that deserves attention in many OA patients. The aim of this research was to verify the action of oral dexketoprofen-trometamol (50 mg) administered early in the morning on morning stiffness in hand OA. Thirty-five patients were compared with 19 controls. The degree of morning stiffness, evaluated by means of the WOMAC scale for OA stiffness, was significantly diminished 40 min after drug administration in treated patients but not in controls. This drug acted rapidly and was effective in reducing morning stiffness in OA of the hands.

One-month follow-up of patients treated by intravenous clodronate for acute pain induced by osteoporotic vertebral fracture.

Disodium-clodronate is one of the most experimented drugs for the management of bone pain caused by vertebral fractures induced by skeletal metastases and myeloma as well as by osteoporosis. In a previous study, treatment with intravenous disodium-clodronate 300 mg/day in saline produced satisfactory relief of moderate or severe back pain in 15 patients with painful vertebral crush. The present study examines the general behavior of pain in patients suffering from vertebral crush when treated with intravenous disodium-clodronate and after discontinuation of medication. At the end of treatment, pain relief was significantly greater in patients treated with disodium-clodronate. After discontinuation of treatment the patients who had been taking disodium-clodronate for pain due to vertebral crush were generally better than those previously on acetaminophen. At the end of follow-up, no significant differences were found between the two groups. In our study, the use of disodium-clodronate was associated with a reduction in the number of days the patients experienced severe pain, which suggests that disodium-clodronate is a first-line drug in the treatment of recent vertebral crush.