Efficacy of therapeutic ultrasound in the treatment of chronic calcific shoulder tendinitis: a randomized trial.

BACKGROUND: Calcific shoulder tendinitis (CST) is characterized by hydroxyapatite crystals deposition in the rotator cuff tendons. Therapeutic exercises have been the mainstay of CST treatment, and evidence for therapeutic ultrasound (T-US) utilization and efficacy is lacking. AIM: This study aimed to determine whether 4500 J T-US combined with therapeutic exercises is superior to therapeutic exercises alone regarding calcification size reduction and symptom improvement in chronic symptomatic CST. DESIGN: This is a double-blind, placebo-controlled study. SETTING: This study was conducted at a University Department for Rheumatic Diseases and Rehabilitation of a University Hospital. POPULATION: Patients with chronic CST were analyzed. METHODS: After eligibility allocation, 46 patients with sonographically confirmed CST were divided into two groups (56 shoulders, 26 per group). Both groups performed the same therapeutic exercises for half an hour under physiotherapist supervision. In the treatment group T-US (4500 J, 10 minutes per session at a frequency of 1 MHz and an intensity of 1.5 W/cm2), and in the placebo group, sham T-US was applied for 4 weeks. Patients were assessed for: calcification size, shoulder pain, global health (GH), shoulder mobility (ROM), handgrip strength, Health Assessment Questionnaire Disability Index (HAQ-DI), Shoulder Pain and Disability Index (SPADI), and overall rehabilitation satisfaction. RESULTS: All assessed variables improved in both groups. A significantly greater reduction in calcification size was recorded in the treatment group compared to placebo: -10.92% (IQR 4.61% to 19.38%) versus -5.04% (2.30% to 7.22%), P=0.008. There was a significantly greater decrease in HAQ-DI, reduction of VAS GH, and an increase in hand grip strength in the treatment group, while no significant differences were observed for other parameters between the groups. CONCLUSIONS: Our results showed that adding the 4500 J T-US to therapeutic exercises in chronic symptomatic CST therapy resulted in greater calcification size reduction immediately following the treatment, as well as hand grip strength, HAQ-DI, and VAS GH improvement. CLINICAL REHABILITATION IMPACT: 4500 J T-US combined with therapeutic exercises is more effective in reducing calcification size than therapeutic exercises alone in the treatment of chronic symptomatic CST.

Anti-TNF Therapy and the Risk of Malignancies and Infections in Inflammatory Rheumatic Diseases - Our Experience.

BACKGROUND: Early diagnosis is the key to successful treatment of inflammatory rheumatic diseases and the use of conventional disease-modifying antirheumatic drugs (csDMARD) and biologic disease-modifying antirheumatic drugs (bDMARD) or biologics have substantially contributed to better disease control. Biological drugs have been approved for the treatment of rheumatoid arthritis (RA), juvenile arthritis (JIA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA). SUBJECTS AND METHODS: The study involved 79 adult patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS), psoriatic arthritis (PsA) or undifferentiated spondyloarthropathy (USpA) - the last three clinical entities belong to a common group called spondyloarthropathies (SpA); receiving anti-TNF therapy at the department of Rheumatology and Rehabilitation, Clinical Hospital Center Zagreb. The duration of therapy was a minimum of 1 month, with the mean duration of 32.0±24.0 months. The infections recorded were infections that appeared during treatment or soon after the treatment was stopped. RESULTS: During the course of therapy 17 patients (21.5%) experienced an infection, with the total number of 21 infections. This resulted in an overall incidence rate (IR) of 9.9/100 patient-years. Of the patients with RA 76.5% developed an infection, which was significantly higher than for patients with SpA (p<0.001). The IR/100 patient-years for all infections in RA patients was 23.7 compared to 2.8 in patients with SpA. Female gender was associated with a significantly higher infection rate (70.6%, p=0.005). There were 8 infections that were considered serious, yielding an IR of 3.8/100 patient-years. There was only one malignancy case in our study. CONCLUSION: Every fifth patient developed an infection during the course of anti-TNF therapy, and more than one third of all infections were serious. RA and female gender was associated with a significantly increased number of infections.

Local Cryotherapy, Comparison of Cold Air and Ice Massage on Pain and Handgrip Strength in Patients with Rheumatoid Arthritis.

BACKGROUND: The main benefits of cryotherapy in rheumatoid arthritis (RA) are in reducing inflammation and swelling and in relieving joint pain. This study aimed to compare the short-term effects of cold air therapy vs. ice massage, on pain and handgrip strength (HGS) in patients with RA. SUBJECTS AND METHODS: The study is a non-randomized clinical trial. Patients were recruited if they had disease activity score (DAS28) ≥3.2 with at least 2 swollen joints on the dominant hand and were consecutively divided into two groups of 15 patients. There was no statistically significant difference in DAS28 score between groups. The first group received cold air therapy at -30°C and the second ice massage of the hands. The pain (visual analogue scale, 0-10), and HGS (kg) were measured immediately prior and after cryotherapy, and 30 and 60 minutes after cryotherapy. Descriptive statistics, Independent Samples T-test, and Paired Samples T-test were used for statistical analysis. RESULTS: Pain intensities for cold air therapy were as follows: 5.33 (±2.44), 3.13 (±2.67), 2.87 (±2.56), 2.80 (±2.73), and for ice massage were: 5.20 (±2.37), 2.87 (±2.42), 2.60 (±2.23), 2.67 (±2.28). In both groups pain was significantly lower immediately after, 30 and 60 minutes after the treatment compared to the baseline (p=0.001). There was no significant difference in pain alleviation between the groups regarding the used method of cryotherapy on all three measured time points. Nonsignificant improvement in HGS occurred after both methods of cryotherapy. There was no significant correlation between pain intensity and HGS. CONCLUSIONS: A single application of cold air therapy and ice massage equally provides immediate and significant pain alleviation in patients with active RA, which is maintained for one hour. There is scientific evidence that HGS is influenced greatly by the disease activity. A single application of cryotherapy could not reduce disease activity explaining recorded nonsignificant effect on HGS.

The Impact of Disease Activity on Quality of Life, Fatigue, Functional Status and Physical Activity in Patients with Ankylosing Spondylitis.

BACKGROUND: Inflammatory back pain and stiffness are the leading symptoms of ankylosing spondylitis (AS). AS progression leads to substantial functional impairment and can reduce quality of life (QoL). The aim of this study was to determine the impact of disease activity on QoL, fatigue, functional status and physical activity. SUBJECTS AND METHODS: One hundred and fifty AS patients were included in the study, their body mass index (BMI) was calculated and they completed questionnaires regarding disease activity (The Bath Ankylosing Spondylitis Disease Activity Index, BASDAI) functional status (The Bath Ankylosing Spondylitis Functional Index, BASFI) spinal mobility (The Bath Ankylosing Spondylitis Metrology Index, BASMI), physical activity (the International Physical Activity Questionnaire, IPAQ), functional disability (The Health Assessment Questionnaire Disability Index, HAQ-DI), fatigue (The Functional Assessment of Chronic Illness Therapy - fatigue, FACIT-F) and QoL (The Short Form Survey-36, SF-36). RESULTS: Patients with inactive disease (BASDAI<4) had significantly better HAQ scores (p=0.001), SF-36 mental component scores - MCS (65.68±19.54 inactive vs. 46.89±21.78 active disease, p=0.001), SF-36 physical component scores - PCS (median score 56.25 inactive vs. 30.00 active disease, p=0.001) and FACIT-F scores (38.49±10.62 inactive vs. 26.21±10.81 active disease, p=0.001). There was no significant difference in patient's physical activity or BMI regarding disease activity (p=0.564 and p=0.162 respectively). Also, there was no significant difference in BASDAI, BASMI or BASFI scores regarding different BMI categories (p=0.818, p=0.474, p=0.436, respectively). CONCLUSION: AS activity increased fatigue, impaired functional ability and QoL, especially the physical component. Although more than half (61.4%) of our patients were categorized as pre-obese or obese according to BMI, this was not related to disease activity, spinal mobility or daily functioning scores. Reported physical activity level had no effect on disease activity. Disease activity influences the course of AS and QoL assessment should be implemented into regular AS evaluation in order to improve treatment outcome.

[Scoring of disease activity using BASDAI and ASDAS method in ankylosing spondylitis]. / Ocjena aktivnosti ankilozantnog spondilitisa primjenom BASDAI i ASDAS instrumenta.

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the most frequently used ankylosing spondylitis activity assesment by which through 6 questions 5 basic diseases symptoms (fatigue, back pain, joint pain/swelling, enthesitic points, intensity and duration of morning stiffness) are being evaluated. In distinction from mentioned, Ankylosing Spondylitis Disease Activity Score (ASDAS) is the first validated index for the AS activity assessment with the patient's assessments of the disease symptoms (back pain, duration of the morning stiffess, activity of the disease, pains and swelling of the peripheral joints) includes the acute phase reactants (SE or CRP). We compared BASDAI and ASDAS indexes to the group of patients with the AS, in order to evaluate their congruence and to evaluate the inluence of SE, fatigue and back pain at obtained values. The cross-sectional study was performed in a group of 36 patients with the AS whose disease activity levels were evaluated by the BASDAI and ASDAS (SE) index. Statistical data analysis was performed by Student t-test and frequency tables for non-parameter data. As it has been expected the significant correlation between BASDAI and ASDAS indexes has been confirmed (r=0.796; p=0.00). BASDAI/ASDAS average value of all of the patients was 4.2/2.8. From 36 patients with the AS according to the BASDAI index 42% had mild active disease (BASDAI <4), while according to ASDAS index 44% patients had very active disease (ASDAS 2.1-.5.3). Higher activity of the disease according to ASDAS index is the result of the elevated sedimentation which is assessed only in ASDAS index. Patients with higher BASDAI index statistically have more significantly expressed fatigue and spinal pain without statistically significant difference in sedimentation (p=0.120). Examinees with higher ASDAS index have also significantly more expressed fatigue and back pain, but unlike BASDAI they have sedimentation (p=0.001). ASDAS is more recent clinical indicator of the AS activities which could be compared to BASDAI instrument. In this group of patients ASDAS seems to be more sensitive index because it discriminates more patients with the active disease.