Turkish Journal of Rheumatology - 2009; 24(1)

Editorial

Deniz EVC�K — 2009-06-01

Complex Regional Pain Syndrome: Epidemiologic Features, Treatment Approaches, Workday Loss and Return to Work/Disability Ratios

Mehmet Zeki K�ralp, �mit Din�er, Engin �akar, Hasan Dursun — 2009-06-01

Objective: The aim of this study was to assess the epidemiologic features of complex regional pain syndrome (CRPS) and the effectiveness of the treatment approaches and to investigate its effects on working life. Material and Methods: The medical records of 106 consecutive patients who were diagnosed with CRPS were reviewed retrospectively regarding demographics, inciting events and injury sites, duration of symptoms, radiologic signs (direct roentgenogram, scintigraphy), treatment modalities, duration of hospitalization, workday loss, treatment outcomes, and disability as a sequela. Results: The most common inciting events were fracture and soft tissue injuries. The mean duration of symptoms was 4.1�3.0 months and of workday loss was 187.5�107.4 days. The clinical outcome in 93 patients (87.7%) was sufficient enough to enable patients to return to their previous work after the rehabilitation program. Conclusion: The management period of CRPS is usually long and causes high workday loss; some patients became disabled despite all therapeutic interventions. (Turk J Rheumatol 2009; 24: 1-5)

Fibromyalgia Syndrome In Geriatric Population

Berrin Leblebici, Nur Turhan, Mehmet Adam, Nuri �etin, Selda Ba�� — 2009-06-01

Objective: The aim of this study was to investigate the frequency and the associated features of fibromyalgia syndrome (FMS) which plays a significant role in the chronic pain syndromes, and also to compare the pain variables in solitary osteoarthritic (OA) patients versus osteoarthritis plus FMS patients, in a group of elderly patients. Material and Methods: One hundred and twenty four patients who aged over 65 and who were consecutively admitted to the Physical Medica and Rehabilitation outpatient clinics were enrolled this study. Sixty-five patients who had no painful diseases other than OA and/or FMS were investigated by means of their clinical and radiological features and essential laboratory tests. The diagnosis of FMS was made according to the criteria of American College of Rheumatology. All FMS patients were also evaluated by Fibromyalgia Impact Questionnaire. Pain parameters included visual analog scale (VAS), the number of degenerative joints, antiinflammatory and analgesic drug intake, and the number of tender points (NTP). Results: The mean age of all patients (97 female, 27 male) was 70.56�5.05 years, the mean age of menapause was 46.04�7.08 years. Forty seven out of 124 (37.9%) were having FMS. Fourtytwo of this FMS patients also had OA. Twenty three patients had only OA. There were statistically significant higher values in VAS scores and incidence of psychiatric problems in OA+FMS patient group (n=42, mean age=69.19�4.23 years), when they were compared to the OA patient group (n=23, mean age=70.6�4.32 years) (p<0.001, p:0.03). Conclusion: In the elderly, FMS is a very common problem, which mostly accompanies degenerative joint diseases and give rise to exagerated painful conditions (Turk J Rheumatol 2009; 24: 6-9)

The Reliability and Cross-Cultured Adaptation of the Boston Questionnaire; in Turkish Illiterate Patients

2009-06-01

Objective: In Turkey, the illiterate patients may not be able to complete many self-administered questionnaires. The aim of this study was to adapt the self-administered Boston questionnaire (BQ) for the assessment of the severity of symptoms and functional status (BQ-SS, BQ-F) in carpal tunnel syndrome to the illiterate Turkish population and investigate the reliability of the cross cultured adaptation. Material and Methods: A total of 120 outpatients with carpal tunnel syndrome (60 literate, 60 illiterate) were assessed using this Turkish version of BQ. Translation/back-translation of the English version BQ was done by using blinded method and independently by four different individuals, and adapted by a team. For illiterate people, the term “writing” was changed as “crocheting” and the statement “holding a book while reading” was modified as “holding the Holy Quran while reading”. Reliability was investigated by the reproducibility and internal consistency. Results: Cronbach's alpha was calculated at 0.914 for BQ-SS scale, 0.94 for BQ-F scale in the illiterate group and at 0.971 for BQ-SS scale, 0.96 for BQ-F scale in the literate group, respectively. The intraclass correlation coefficients were excellent and range between 0.89 and 0.96 for BQ-SS and BQ-F in the illiterate and the literate patients. Conclusion: This adapted version of BQ provides a reliable tool in iliterate Turkish patients with carpal tunnel syndrome. For application of self-administered questionnaire, some conceptual modifications should be required for accommodation of the different educational levels. (Turk J Rheumatol 2009; 24: 10-6)

Serologic and Molecular Diagnosis of Human Parvovirus B19 in Rheumatoid Arthritis Patients

2009-06-01

Objective: To investigate Human Parvovirus (HPV) B19 IgG and IgM antibody levels and B19 viral DNA using PCR method in the serum of Rheumatoid arthritis (RA) patients to determine the role of B19 in the ethiopathogenesis of RA. Material and Methods: Sixty patients who met the criteria of American Rheumatism Association for RA and who were followed in our outpatient clinic, 2 patients with a diagnosis of Juvenile RA and 29 patients with a diagnosis of osteoarthritis (OA) as control group were included in the study. Peripheral venous blood sample was obtained from the patients to investigate IgG and IgM against HPV B19. HPV B19 IgM and IgG were investigated using micro Enzyme Linked Immunosorbent Assay method. B19 viral DNA isolation was performed using Real Time PCR. Results: Ages and sex were not different between groups (p>0.05). HPV B19 IgM positivity was determined in 7 (%11.3) in RA and in 4 (%13.8) patients in OA group (p>0.05). B19 IgG positivity was determined in 29 (%46.8) in RA and in 17 (%58.6) patients in OA group (p>0.05). B19 DNA was investigated using PCR in 10 patients among 11 patients who had B19 IgM positivity. B19 DNA was isolated in 5 of 7 (%71.4) RA patients who were positive for B19 IgM. But no B19 DNA could be isolated in 3 osteoarthritis patients. Although B19 DNA was isolated markedly higher in RA group, the difference was not significant between groups because B19 IgM was positive in a small number of patients (p>0.05). Conclusion: We found the incidence of HPV B19 IgM and IgG in the serum of RA patients not different from OA patients. We assessed viral DNA positivity by PCR as reinfection in former cases. We believe that we will get clear evidence about the role of B19 in RA by gathering the results of different studies. (Turk J Rheumatol 2009; 24: 17-20)

The Effect of Grip Strength on Bone Mineral Density Measurements in Postmenopausal Sedentary Women

Filiz Sivas, Fatma Yaz�c�, K�r�at �zoran — 2009-06-01

Objective: The present study aimed to investigate the effect of grip strength on dominant and non-dominant forearm, hip and lumbar bone mineral density (BMD) measurements in postmenopausal women. Material and Methods: A total of 93 postmenopausal women (age range: 50-70 years) were included in the study. The dominant extremity was determined by querying patients regarding which hand they use while eating or performing a task. Following measurements regarding height and body weight for body mass index (BMI), grip strength was measured in all patients using the Jamar hand dynamometer device. BMD measurements were determined in the dominant and non-dominant forearm ultradistal end (UDE), 1/3 radius distal end (RDE) and forearm total, and dominant and non-dominant side femur neck, total hip, and lumbar L1-4 regions. Results: When the hand grip strengths of dominant and nondominant extremities were compared along with the forearm BMD values, only the hand grip strength of the dominant side was significantly higher than the non-dominant side. There was a significant correlation between the dominant and nondominant extremity RDE, UDE, and forearm total BMD measurements and the grip strength of the same side. The multivariate regression analyses revealed that the determining effect of grip strength on the forearm BMD measurements of the dominant and non-dominant extremities was weak. There was also a correlation between L1-4 total, dominant and non-dominant extremity femur neck and total hip BMD values and the hand grip strengths. However, the regression analyses revealed that grip strength did not have a determining effect on L1-4 total and dominant and non-dominant extremity hip BMD values. The factors affecting BMD values of these regions were detected as BMI, age and duration of menopause. Conclusion: The present study concluded that the effect of muscle strength on BMD measurements in postmenopausal sedentary women was site-specific rather than systemic. (Turk J Rheumatol 2009; 24: 21-6)

Anti-TNF Agents in Beh�et's Disease Treatment

Semih Tatl�can — 2009-06-01

Beh�et's disease (BD) is a systemic vasculitis affecting all vessel types. The etiology and pathogenesis of the disease are not clearly known. Tumor necrosis factor α (TNF-α) is a major proinflammatory molecule that has been shown to have a critical role in the pathogenesis of BD. This role was also supported by the articles reporting the effectiveness of anti-TNF agents in the treatment of BD. Infliximab is the most widely used anti-TNF agent in the treatment of BD patients with manifestations of eye, central nervous system, gastrointestinal system, vascular system and joint involvements. Although infliximab seems to be more effective and faster than the other two agents in the treatment of all manifestations, the relative frequency of infusion reactions and the administration route may limit the usage of this drug. Etanercept was found to be more effective in the treatment of patients with mucocutaneous disease and arthritis compared to other manifestations. In spite of its effectiveness being determined in only a limited number of manifestations, the easy administration route of etanercept can be an advantage in selected indications. (Turk J Rheumatol 2009; 24: 27-38)

Low Back Pain in Pregnancy

Bar�� Nac�r, Aynur Karag�z, H. Rana Erdem — 2009-06-01

Pregnancy-related low back pain is a common problem during pregnancy. More than half of all pregnant women experience low back pain at some time during pregnancy. The pain can vary from a mild discomfort to being severe and disabling. In one-third of these women, pain is a severe problem compromising activities of daily living, work and sleep. The awareness of the possible impact of low back pain on the quality of life and the associated costs to society has increased medical attention over the last decade. Pain usually develops between the fifth and seventh month of pregnancy but may appear as early as the first trimester. Moreover, some women who experience back pain during pregnancy experience persistent back pain in the postpartum period or have an increased risk of back pain in subsequent pregnancies, and many women with chronic back pain link its onset to a pregnancy. Despite its high frequency, there are some ambiguities inherent in the terminology, diagnosis and classification. The etiology and pathogenesis are not yet clearly understood. The etiology of pain is probably related to a combination of mechanical, hormonal and vascular contributing factors. Low back pain in pregnancy is most commonly subdivided into lumbar pain and posterior pelvic pain. This subdivision is important in terms of both management and prognosis. Characteristic findings and treatment may differ between the two categories. Accurate assessment and effective treatment are important for managing the low back pain of pregnancy. The purpose of the present article was to provide a summary review of the performed studies on pregnancy-related low back pain. (Turk J Rheumatol 2009; 24: 39-45)

Management of Inflammatory Rheumatologic Diseases with Orthoses

Taciser Kaya — 2009-06-01

An orthosis is a device applied to the body externally to relieve pain, stabilize or immobilize, prevent or correct deformity, improve function, positioning, supporting and asist weak muscles. It can be applied to any part of the body, such as the hand, elbow, shoulder, head, neck, back, hip, knee, ankle and foot. As part of the comprehensive management of rheumatoid arthritis (RA) and related conditions, orthoses may be recommended to treat symptoms of the disease and improve performance of everyday activities. However orthosis prescription is not a simple process; clinicians and patients need to work together to determine the daily wear pattern that maximizes benefit and minimizes inconvenience according to the patients' individual needs. Besides, patients wearing orthoses should be instructed about daily and total usage duration, necessitating orthosis wearing tasks, hygienic rules and to avoid undesirable effects of orthosis usage. In this manuscript, the articles relating orthosis usage in inflammatory rheumatologic diseases have been reviewed. (Turk J Rheumatol 2009; 24: 46-50)

A Rare Cause of Reactive Arthritis: Giardia Lamblia

Dilek Karaku�, Nil�fer Kutay Ordu G�kkaya, F�gen Oktay, Halil U�an — 2009-06-01

Although many of parasitic infestations are known to cause arthritis development, articular findings related to parasitosis is rarely discussed in literature. The protozoa, Giardia lamblia is often known as gastroenteritis agent, on the other hand rarely causes reactive arthritis. The clinical presentation related to articulation are arthritis and arthralgia. In our report, a case with reactive arthritis due to Giardia lamblia is presented with emphasis on the differences in diagnosis and treatment. (Turk J Rheumatol 2009; 24: 51-2)

Cervical Myelopathy Caused by Os Odonteideum: Case Report

Cengiz Bahad�r, Vildan Yaman, Asl�han Tarakta� — 2009-06-01

Congenital anomalies of the odontoid process have been described in the literature. Os odonteideum is a seperate odontoid process from the body of the axis. It is the most common anomaly of the odontoid process. It may cause cervical instability, atlontoaxial dislocation and myelopathy. Os odontoideum must be distinguished from an acute fracture of the dens. In this report, a case with os odontoideum complicated with asymptomatic myelopathy and cervical disc herniation was discussed. (Turk J Rheumatol 2009; 24: 53-5)

Undifferentiated Connective Tissue Disease: A Case Report

Ali Aydeniz, �zlem Alt�nda�, Sava� G�rsoy — 2009-06-01

Undifferentiated connective tissue diseases (UCTD) are heterogeneous disorders characterized by a wide variety of signs and symptoms. Approximately 30% of cases of the disease will evolve to defined connective tissue disease; however, 70% will maintain an undifferentiated clinical course or go to complete remission. The most characteristic symptoms of UCTD present in the form of arthralgias, arthritis and Raynaud's phenomenon. The definite classification criteria to identify UCTD are not yet available. Although these conditions are generally benign, an evolution to connective tissue diseases may occur; therefore, a regular follow-up of the patients is strongly advised. We report a case that remained undifferentiated for seven years and responded well to preventive measures and disease-modifying antirheumatic drug therapy. (Turk J Rheumatol 2009; 24: 56-7)

Succesful Treatment of Intermittant Hydrartrosis with Colchicine: A Case Report

Mehmet Adam, Zafer Y�ld�z, G�l Mete, Berrin Leblebici — 2009-06-01

Intermittent hydrarthrosis (IH) is a monoarticular disease of unknown etiology, characterized by episodic effusions, and it usually affects middle-aged women. Acute phase reactants are within normal range during attacks. Although this non-destructive disease has no definite treatment, non-steroidal anti-inflammatory drugs, intraarticular steroids, and radioactive and surgical synovectomy have been used. Here, we report a 37-year-old female with IH in whom successful remission was obtained with colchicine treatment. This case is of interest since to our knowledge there have been only two patients reported in the literature with remission of IH achieved by colchicine. (Turk J Rheumatol 2009; 24: 58-9)

Atherosclerosis in Patients with Osteoporosis
Osteoporoz Hastalar�nda Ateroskleroz Riski

�zlem Alt�nda� — 2009-06-01