Frequency of fibromyalgianess in patients with rheumatoid arthritis and ankylosing spondylitis: A multicenter study of Turkish League Against Rheumatism (TLAR) network.

Objectives: This study aimed to evaluate the frequency of fibromyalgianess, fibromyalgia syndrome (FS), and widespread pain in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and their relationship with clinical and demographic parameters. Patients and methods: This cross-sectional multicenter trial was performed in 14 centers across Türkiye between June 2018 and November 2019. Out of 685 patients recruited from the accessible population, 661 patients (342 RA, 319 AS; 264 males, 397 females; mean age: 48.1±12.9 years; range, 17 to 88 years) met the selection criteria. In these cohorts, those who did not meet the criteria for FS and had widespread pain (widespread pain index ≥7) were evaluated as a separate group. Clinical status and demographic parameters of patients in both cohorts were evaluated as well as the evaluations of RA and AS patients with widespread pain (widespread pain index ≥7) and RA and AS patients with FS groups. In addition, correlations between polysymptomatic distress scale (PSD) scores and Visual Analog Scale (VAS), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and Disease Activity Score using 28 joint counts for RA patients and VAS, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Ankylosing Spondylitis Disease Activity Score (ASDAS) for AS patients were analyzed. Results: Frequencies of patients with FS and patients who had PSD scores ≥12 were 34.1% and 44.4% in all RA patients, respectively. Moreover, FS and PSD scores ≥12 were found in 29.2% and 36.9% of all AS patients, respectively. PSD scores of RA patients with FS were higher than all RA patients and RA patients with widespread pain. SDAI and CDAI scores of RA patients with FS were higher than all RA patients and RA patients with widespread pain. Similarly, PSD scores of AS patients with FS were higher than all AS patients and AS patients with widespread pain. ASDAS-erythrocyte sedimentation rate and BASDAI scores of AS patients with FS were found higher than all AS patients and AS patients with widespread pain. Conclusion: Disease activity scores, including pain in RA and AS, were higher in the presence of FS or fibromyalgianess. It may be related to clinical parameters, but cohort studies with long-term follow-up are needed to reveal causality. Additionally, to avoid overtreatment, coexistence of fibromyalgianess should be kept in mind in patients who have inflammatory diseases such as RA and AS, particularly with intractable widespread pain.

Comparison of effects of low level laser therapy and local corticosteroid injection in the treatment of plantar fasciitis.

Objectives: The purpose of the study was to compare low-level laser therapy (LLLT) and local corticosteroid injection in the treatment of plantar fasciitis. Patients and methods: This retrospective study was performed with 56 patients (6 males, 50 females; mean age: 44.7±10.1 years; range, 18 to 65 years) between January 2015 and March 2016. The patients were equally divided into two groups: Group 1, comprising patients who underwent a one-time local corticosteroid injection into the heel by the same physician, and Group 2, including patients who had gallium arsenide laser therapy at a wavelength of 904 nm lasting 10 sessions. Evaluations were done at pre-treatment, post-treatment, and two weeks, one month, and three months after the post-treatment evaluation. The post-treatment evaluation was accepted as the 10th day after the injection in Group 1 and as the time after the last session of the laser treatment in Group 2. Each visit was compared with the previous visit for within-group analysis. The Visual Analog Scale (VAS), Heel Tenderness Index (HTI), and Foot Function Index (FFI) were assessed. Results: Pain scores in Group 1 and Group 2 were not associated with statistically significant differences (p>0.05). Within-groups analysis demonstrated statistically significant differences concerning VAS subgroups (p <0.05), except for Group 2's resting VAS values (p=0.159). No statistically significant differences were found between groups in the means of FFI scores (p>0.05). Statistically significant differences were observed regarding within-group analyses for all subscores (p <0.001). No statistically significant differences were observed between the two groups for all visits regarding HTI scores (p>0.05). Statistically significant differences were found between baseline and the first after-treatment visit in all groups (p <0.05). Statistically significant differences were found in the first (p=0.020) and third (p=0.010) months compared to the one-week follow-up in Group 2 regarding HTI scores. Conclusion: Both LLLT and local corticosteroid injection for plantar fasciitis have positive effects for three months after treatment. However, LLLT is more effective than local corticosteroid injection at the end of the third month in local tenderness.

Long-Term Effectiveness of Combined Intermittent Pneumatic Compression Plus Low-Level Laser Therapy in Patients with Postmastectomy Lymphedema: A Randomized Controlled Trial.

Background: Upper limb lymphedema may be revealed after breast cancer and its treatment. Among different treatment approaches, intermittent pneumatic compression (IPC) therapy and low-level laser therapy (LLLT) are reported as effective modalities in the treatment of postmastectomy upper limb lymphedema (PML). The aim of the current study is to investigate the long-term effectiveness of combined IPC plus LLLT versus IPC therapy alone in patients with PML. Methods and Results: The patients were allocated into two groups in this single-blinded, controlled clinical trial. Group I received combined treatment with IPC plus LLLT (n = 21) and group II received only IPC (n = 21). IPC treatment was given 5 sessions per week for 4 weeks (20 sessions). LLLT was also performed 5 sessions per week for 4 weeks (20 sessions). Clinical evaluations were performed before and after the treatment at the 3, 6, and 12-month follow-up visits. According to within-group analysis, statistically significant improvements in the circumference difference (Cdiff) and grip strength were observed in both groups (for Cdiff, p = 0.018 and p = 0.032, respectively; for grip strength, p = 0.001 and p = 0.046, respectively). Visual analog scale values for arm pain and shoulder pain during motion were decreased only in group I. Conclusion: Both interventions have positive effects on lymphedema, grip strength, and pain. Long-term effects of combined therapy, especially on pain, are slightly superior to the pneumatic compression alone.

The Effect of Pregabalin on Bone Metabolism.

The aim of the study was to determine the effect of pregabalin as monotherapy on biochemical markers and bone mineral density. 40 patients diagnosed with neuropathic pain or fibromyalgia syndrome who were using pregabalin for at least 6 months and age and sex matched 40 healthy individuals were recruited for this cross-sectional study. Bone mineral density of both groups were measured by dual energy x ray absorbsiometry(DXA), bone biochemical markers, serum calcium, and vitamin D levels were investigated. Association between pregabalin use and bone biochemical markers, serum calcium, vitamin D levels were evaluated. The mean age of 40 patients (27 females, 13 males) was 40.6 ± 7.1 years and the mean age of 40 healthy individuals (27 females, 13 males) was 40.4 ± 7.3 years. The other demographic data were similar. There were no significant differences in lumbar and femur neck BMD scores between 2 groups. Also, there were no associations neither between pregabalin use and biochemical markers including serum calcium levels nor between pregabalin use and vitamin D levels. However, the patients who had been used pregabalin less than 24 months had low lumbar t and z scores than patients who had been used pregabalin more than 24 months. This effect was more prominent in male patients. Although no negative effect of pregabalin was found on bone metabolism in these group of patients, we have suggested that further prospective controlled studies with large sample size in different age groups could provide new data about the effects of pregabalin on bone metabolism. We suggest to investigate the bone metabolism especially in male patients on pregabalin treatment who had been used pregabalin treatment less than 24 months.

Sacroiliitis Detected by Magnetic Resonance Imaging in Patients With Systemic Sclerosis.

OBJECTIVES: This study aims to evaluate the magnetic resonance imaging (MRI) findings of sacroiliac joints in a selected group of patients with systemic sclerosis (SSc). PATIENTS AND METHODS: This retrospective study included 30 patients (2 males, 28 females; mean age 44.1±12.5 years; range, 24 to 70 years) with SSc who underwent MRI of sacroiliac joints. Lesions were defined according to Assessment of SpondyloArthritis International Society (ASAS)/Outcome Measures in Rheumatology MRI group criteria. Clinical features, conventional radiograms of sacroiliac joints, presence of inflammatory back pain, human leukocyte antigen B27 (HLA-B27), and C-reactive protein (CRP) levels were extracted from patient records. RESULTS: Eleven of thirty patients (37%) revealed sacroiliitis on MRI (five with chronic, three with active sacroiliitis, and three with both active and chronic forms). On conventional radiographic examination, six patients had sacroiliitis (20%). In all of these six patients, sacroiliitis was also detected on MRI. CRP levels and number of patients with inflammatory back pain were found to be higher in the patients with active sacroiliitis (p<0.05). Seven patients were diagnosed as spondyloarthritis according to ASAS criteria. CONCLUSION: Sacroiliitis was detected more frequently by MRI compared to conventional radiographic examination. MRI is suggested to be the preferred method for evaluating sacroiliitis in SSc patients.

Effectiveness of electrical stimulation after administration of botulinum toxin in children with spastic diplegic cerebral palsy: A prospective, randomized clinical study.

OBJECTIVES: The aim of the study was to investigate the effectiveness of electrical stimulation to agonist muscles after injection of Botulinum toxin A (BTX-A) in children with spastic diplegic cerebral palsy (SDCP). PATIENTS AND METHODS: Between October 2009 and October 2010, 38 patients with SDCP (19 males, 19 females; mean age 6.3 years; range, 4 to 10 years) were included. The patients were able to walk independently or with minimal assistance by foot equine and had spasticity in the calf muscles between Grades 1+ and 3 according to the Modified Ashworth Scale (MAS). The patients received either BTX-A injection + electrical stimulation (Group 1, n=19) or BTX-A injection alone (Group 2, n=19). All patients were evaluated using the MAS, Penn Spasm Frequency Scale (PSFS), Gross Motor Function Measure-88 (GMFM-88) (Dimensions D and E), and walking velocity. RESULTS: A decrease in spasticity was evident for the right, left, and bilateral lower extremities for both groups (p<0.05). There were no statistically significant differences in the MAS, PSFS, GMFM-88 (Dimensions D and E), and walking velocity between the groups. CONCLUSION: Our study results showed that both patient groups benefited from the treatment and the administration of electrical stimulation to the gastrocnemius motor points produced no additional benefit for patients with SDCP.

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.

Association between phantom limb complex and the level of amputation in lower limb amputee.

OBJECTIVE: The aim of this study was to evaluate the natural course of phantom limb complex without any treatment after lower limb amputation. METHODS: The study design was consisted of a combination of retrospective review and cross-sectional interview. 101 patients with lower limb amputation were included into the study. Patients were divided into three groups according to the amputation level: i) from hip disarticulation to knee disarticulation (including knee disarticulation) (25 patients, mean age: 55.9, 19 males, 6 females) ii) transtibial amputation (below knee to ankle including ankle disarticulation) (41 patients, mean age: 58.6, 33 males, 8 females) iii) below ankle to toe amputation (35 patients, mean age: 58.7, 26 males, 9 females). The patients were evaluated on both early postoperative period (EPP) and sixth months after the surgery (ASM). The data related amputation including amputation date, level, cause, stump pain (SP), phantom limb pain (PLP), components of PLP, phantom sensation (PS) were recorded based on the information obtained from patients' and hospital files. RESULTS: Statistically significant differences were found for pain intensity (VAS) between groups for SP and PLP at EPP (p < 0.001, p = 0.036; respectively). The mean VAS score in Group I for SP and PLP was higher than other groups. This differences for SP and PLP did not continue at ASM assessment (p = 0.242, p = 0.580; respectively). CONCLUSION: VAS scores for SP in above knee amputations and VAS scores for PLP in above knee amputations and below ankle amputations were higher at EPP. But these high scores had disappeared over time. Management strategies have to be considered particularly in the early postoperative period in patients who had undergone above knee amputation. LEVEL OF EVIDENCE: Level III Prognostic study.

Assessment of demographic and clinical characteristics on functional status and disability of patients with stroke.

OBJECTIVE: To determine the effects of demographic and clinical characteristics on mobility, disability, and activities of daily life of patients with stroke. METHODS: This cross-sectional clinical study was performed in the Department of Physical Medicine and Rehabilitation in Cukurova University Faculty of Medicine in Adana, Turkey, between February 2011 and December 2011. The study included 126 patients with stroke. The Brunnstrom recovery scale (BRS), functional ambulation classification scale (FACS), modified Barthel index (MBI), modified Rankin scale (MRS), and Rivermead mobility index (RMI) were used in the evaluation of the functional status of stroke patients. Correlations between each scale and parameters including age, etiology, and duration of hemiplegia were assessed. RESULTS: The major etiology of stroke was found as ischemic (77%). Hypertension was a major risk factor in both genders (72% for males, 85% for females). Statistically significant differences were found between ischemic and hemorrhagic stroke patients regarding the RMI, MBI, BRS, and the FACS (p<0.001). Age had a poor negative correlation with the FACS and RMI. CONCLUSION: It is suggested that age is an important risk factor for the development of stroke, but it has no strong effect on functional status and disability in patients with stroke. The BRS, FACS, MBI, MRS, and RMI scales can be used in stroke patients whether they are under or over 65 years old in order to evaluate functional status and disability.

Charcot's neuroarthropathy of the hand in a patient with diabetes mellitus.

Charcot's neuroarthropathy (CNA) is a destructive disease associated with a reduced proprioceptive sensation. Diabetes mellitus (DM) is one of the most common etiological factor for CNA which typically affects ankles and small joints of feet. Neuroarthropathy seen in upper extremity in patients with DM is a rare clinical condition. In this report, we presented a case of CNA with hand involvement who had type-II DM. Neuroarthropathy was rapidly progressed and destructive changes were observed in right hand joints after a minor trauma in current case. Charcot's neuroarthropathy may rarely occur in the joints of hand in patients with DM. Early diagnosis of CNA is important in order to protect joints and avoid further disability.

Is there any link between joint hypermobility and mitral valve prolapse in patients with fibromyalgia syndrome?

The objective of the present study is to determine whether benign joint hypermobility syndrome (BJHS) modifies the risk of mitral valve prolapse (MVP) in patients with fibromyalgia (FM). Female patients fulfilling the 1990 American College of Rheumatology (ACR) diagnostic criteria for FM were included into the study. Joint hypermobility and BJHS were assessed using Beighton's scoring system and Brighton criteria, respectively. Echocardiograpic evaluation was performed in order to test the presence of MVP. Of the 75 female FM patients, 68.0 % (n = 51) and 20.0 % (n = 15) were diagnosed with BJHS and MVP, respectively. The frequencies of both MVP and BJHS seemed higher than the general population prevalence (p = 0.000 for both). The frequency of MVP was significantly higher in patients with BJHS than that in patients without BJHS (p = 0.028). In addition, BJHS was found to increase the risk of MVP approximately ninefold [odds ratio (OR) 8.7, 95 % confidence interval (CI) 1.1-70.7]. As a result, BJHS and MVP are both common in female patients with FM. Moreover, among the female patients with FM, those with BJHS are about nine times more prone to MVP than those without BJHS. Cardiologic assessment might be added to the routine follow-up strategies in FM patients with BJHS in order to exclude the cardiac pathologies, especially MVP.

A Rare Cause of Shoulder Pain: Monostotic Fibrous Dysplasia.

Fibrous dysplasia is a rare bone disease which has a wide spectrum of symptoms depending on the involvement area such as pain, deformity, fracture, dyspnea or visual loss. One of the rare involvement areas is the bones around the shoulder. Fibrous dysplasia presents in two forms named monostotic or polyostotic. In this article, we present a case with monostotic fibrous dysplasia of the humeral head who admitted to our clinic with shoulder pain.

The effects of aquatic, isometric strength-stretching and aerobic exercise on physical and psychological parameters of female patients with fibromyalgia syndrome.

[Purpose] There are various treatment modalities for fibromyalgia syndrome (FMS), which is characterized by widespread pain and fatigue. The aim of this study was to investigate the effects of aquatic, aerobic and isometric strength-stretching exercises on the physical and psychological parameters of patients with FMS. [Subjects and Methods] Seventy five female patients with FMS were randomly selected and divided into three groups. Patients (18-50 years) were treated for 3 months using one of three methods: a home-based isometric strength and stretching exercise program (ISSEP), a gym-based aerobic exercise program (AEP), and a pool-based aquatic aerobic exercise program (AAEP). Items evaluated were: the number of tender points, Visual Analog Scale (VAS), Fibromyalgia Impact Questionnaire (FIQ), the Six-Minute Walk Test (6MWT), SF-36 physical and mental health scores, and the Beck Depression Inventory (BDI). [Results] The results revealed that AAEP was the most effective treatment of the three. All of the groups showed significant improvements in all variables between pre-and post-test, except the mean values of VAS and BDI in ISSEP. [Conclusion] The results suggest that aquatic aerobic exercise program is more effective than AEP and ISSEP in the treatment of FMS.

Ochronotic involvement of the aortic and mitral valves in a 72-year-old man.

Ochronosis, an autosomal recessive metabolic disorder, causes an excess of homogentisic acid that results in adverse pigmentation, calcification, and inflammation of cartilaginous and other tissues. Cardiovascular abnormalities are less frequently reported than are other manifestations. In rare cases, ochronosis can cause valvular heart disease. We report the case of a 72-year-old man with aortic stenosis and mitral insufficiency who was diagnosed with ochronosis while undergoing surgical aortic and mitral valve replacement. We discuss the history and surgical management of alkaptonuric ochronosis.

Low-level laser and local corticosteroid injection in the treatment of subacromial impingement syndrome: a controlled clinical trial.

OBJECTIVE: To investigate the effectiveness of low-level laser treatment and local corticosteroid injection in patients with subacromial impingement syndrome. DESIGN: Controlled clinical trial. SETTING: Physical Medicine and Rehabilitation outpatient clinic. SUBJECTS: One hundred thirty-five patients with subacromial impingement syndrome. INTERVENTION: The patients were allocated to three groups: local corticosteroid injection (group I); sham laser treatment (group II); and low-level laser treatment (group III). Low-level laser treatment was performed three times per week for a total of nine sessions. Local corticosteroid injections were administered twice, with an interval of 10 days between each. The patients were assessed at pre-treatment, post-treatment and three and six months after the first visit. MAIN MEASURES: The primary outcome of the study was pain intensity (visual analog scale) during activity and at rest. The secondary outcomes were, shoulder functional status and quality of life measured by the University of California at Los Angeles rating score (UCLA) and Nottingham Health Profile (NHP) scale respectively. RESULTS: Significant differences were observed between groups I and II and between groups II and III regarding pain during activity and at rest scores at all of the visits (p<0.05). Nevertheless, significant improvement was observed between groups I and III regarding pain during activity only at post-treatment (p=0.013). The UCLA scores were significantly changed in all three study groups at all of the visits (p<0.05). CONCLUSION: The effectiveness of low-level laser treatment was similar to that of local corticosteroid injection in patients with subacromial impingement syndrome. We concluded that both low-level laser treatment and corticosteroid injection were more effective than sham laser treatment.

Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis.

OBJECTIVES: To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS). METHODS: A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated. RESULTS: Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively. CONCLUSIONS: Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.

Coexistência de osteoartropatia hipertrófica e mielofibrose.

Hypertrophic osteoarthropathy (HOA) is a condition characterized by arthralgia/arthritis, clubbing, and periosteal reaction. Primary form of HOA is observed at early ages of life and is hereditary in nature. Secondary HOA is more frequently seen in clinical setting and occurs as a result of various disorders including inflammatory and malignant diseases. Regression in HOA may be seen after the treatment of underlying condition. In this report, we presented a case of HOA coexisted with myelofibrosis and reviewed the current literature.

Description of the registry of patients with ankylosing spondylitis in Turkey: TRASD-IP.

A web-based application patient follow-up program was developed to create a registry of patients with ankylosing spondylitis (AS) by the Turkiye Romatizma Arastirma Savas Dernegi (TRASD) AS Study Group. This study describes the methodological background and patient characteristics. The patient follow-up program is a web-based questionnaire, which contains sections on socio-demographic data, anamnesis, personal and family history, systemic and musculoskeletal examination, laboratory and imaging data and treatment. Between October 1, 2007 and February 28, 2009, 1,381 patients from 41 centers were included in the registry (1,038 males [75.2%]; mean age 39.5 ± 10.7 years). Mean disease duration was 12.1 ± 8.5 years, and mean time from initial symptom to diagnosis was 5 ± 6.8 years (median 2 years). HLA-B27 positivity was detected in 73.7% of 262 patients tested. Manifestations of extraarticular involvement were anterior uveitis (13.2%), psoriasis and other skin and mucous membrane lesions (6%) and inflammatory bowel disease (3.8%). The prevalence of peripheral arthritis was 11.2%. In 51.7% of patients, the Bath AS Disease Activity Index was ≥4. But since our patients consisted of the ones with more severe disease who referred to the tertiary centers and needed a regular follow-up, they may not represent the general AS population. Disease-modifying anti-rheumatic drugs were being used by 41.9% of patients, with 16.4% using anti-TNF agents. TRASD-IP (Izlem Programi: Follow-up program) is the first AS registry in Turkey. Such databases are very useful and provide a basis for data collection from large numbers of subjects. TRASD-IP gives information on the clinical and demographic profiles of patients, and the efficacy and safety of anti-TNF drugs, examines the impact on quality of life, and provides real-life data that may be used in cost-effectiveness analyses.