Turkish Journal of Rheumatology - 2009; 24(2)

Editorial

Deniz Evcik — 2009-07-01

Peripheral Neuropathy in Rheumatoid Arthritis Patients: An Electroneurophysiological Study

Lale Akbulut Aktekin, Hilmi G�zl�kaya, Hatice Bodur, P�nar Borman, �zlem K�z — 2009-07-01

Objective: The aim of this study was to evaluate the frequency of peripheral nervous system involvement with electrophysiological studies in rheumatoid arthritis (RA) patients whose neurological examination findings were within the normal range. Material and Methods: Fifty-six RA patients and 32 healthy control subjects were included. Demographic characteristics, duration of disease and drug use of the patients were recorded. Laboratory variables and Ritchie articular index were used to evaluate disease activity. Electrophysiological studies were performed in all patients and control subjects. Median, ulnar and peroneal nerve motor nerve conduction studies (CVs), F wave, and median, ulnar, and sural nerve sensory CVs were recorded. Results: The frequency of neuropathy was higher in the patients with RA than in the control group. Neuropathy was detected in 20 (36%) RA patients: 3 (5%) had sensorimotor polyneuropathy, 7 (13%) had low sural sensory nerve conduction or absence of action potentials, 2 (4%) had carpal tunnel syndrome, 6 (11%) had low amplitude peroneal compound muscle action potentials, 1 (2%) had low amplitude peroneal compound muscle action potential and low ulnar sensory nerve conduction, and 1 (2%) had low sural and ulnar sensory nerve conduction. Neuropathy was determined in 5 of 13 patients using corticosteroids and in 15 of 43 patients who were not using corticosteroids. There was no statistically significant difference between the electrophysiologic findings of subgroups in terms of the corticosteroid therapy and positivity of Schirmer test and rheumatoid factor. There was no correlation between the electrophysiological parameters and disease activity in patients with RA. In the control group, 2 (6%) cases had electrophysiologically determined neuropathy; frequency of neuropathy was higher in the patients with RA when compared with the control group, and the difference was statistically significant (p<0.01). Conclusion: Clinical evaluation of neuropathy in RA patients is difficult since neuropathic symptoms are frequently confused with arthritis. To detect neuropathy earlier in patients with RA, electrophysiological studies are recommended as routine diagnostic procedure even in the absence of clinical nerve involvement. (Turk J Rheumatol 2009; 24: 62-6)

Plantar Pressure Changes of Patients with Heel Valgus in Rheumatoid Arthritis

Nurettin Tastekin, Hakan Tuna, Murat Birtane, Kaan Uzunca — 2009-07-01

Objective: Long-standing rheumatoid arthritis (RA) causes foot problems in approximately 90% of the patients. In this study, we aimed to document the plantar pressure distribution changes in RA patients with heel valgus and to compare results in those without valgus. Material and Methods: This study was performed on 22 feet of 11 RA patients with bilateral heel valgus (Group 1) and 28 feet of 14 RA patients without heel valgus deformity (Group 2). Both static and dynamic pedobarographic evaluations were performed in both groups to determine the plantar pressure values and to make comparisons between the groups. Erosion scores of both groups were also compared. Results: In dynamic pedobarographic evaluation, only the plantar contact area was found to be greater in Group 1 than Group 2. However, in the static evaluation, forefoot pressure percentage, plantar contact area and forefoot plantar contact area values were higher in Group 1 than Group 2. In radiographic evaluation, erosion scores were again found to be higher in Group 1. Conclusion: According to results of the pedobarographic evaluation in this study, heel valgus deformity in the RA patients led to increases in plantar contact area and forefoot pressure percentages. (Turk J Rheumatol 2009; 24: 67-71)

The Effect of Mud Pack Treatment in Knee Osteoarthritis

2009-07-01

Objective: The aim of this study was to evaluate the efficacy of mud pack treatment in patients with knee osteoarthritis (OA). Material and Methods: Fifty-seven patients with bilateral primary OA of the knee were enrolled in the study. Patients were divided into two groups based on their availability for mud application during the study period. The patients in the study group (32 patients) were subjected to daily mud pack treatment on weekdays only for three weeks, applied to both knees for 30 minutes (min) at 45�C (total 15 applications). Mud applications were done in the musculoskeletal outpatient clinic by the same person. The patients in the control group (25 patients) had analgesic treatment with acetaminophen 2 g/day. All patients were evaluated three times by assessors who were blinded to both the intervention and evaluation period: (1) at the baseline, (2) immediately after the 15th application, and (3) 30 days after the end of the treatment. Western Ontario and McMaster Universities osteoarthritis index (WOMAC), pain intensity (as measured with 100 mm VAS) and patient's and physician's assessment of disease severity index were the primary outcome measures of the study. Results: As compared to the baseline, significant decreases were observed in both groups in terms of WOMAC, pain intensity, and disease severity index scores. The improvements were found to be superior in the study group as compared to the controls. Moreover, a significant number of patients in the study group had minimal clinically important improvement when compared to the control group. Conclusion: Mud pack treatment significantly improves the pain and functional status of patients with knee OA. (Turk J Rheumatol 2009; 24: 72-6)

Factors Affecting the Quality of Life in Patients with Fibromyalgia

Nuri �etin, �eniz Ak�ay Yalbuzda�, Mehmet Tu�rul Cab�o�lu, Nur Turhan — 2009-07-01

Objective: Fibromyalgia is a chronic musculoskeletal pain syndrome characterized by diffuse pain and specific painful tender points. This study was planned to gain a better understanding of the factors that may impact the quality of life of patients with fibromyalgia. Material and Methods: The study was carried out in the Physical Therapy and Rehabilitation outpatient clinic with 35 women with fibromyalgia and 20 healthy women with no current or past medical history as controls. The subjects were evaluated with digital palpation to test tender points, by algometric measurements to test pressure pain threshold, the Short-Form McGill Pain Questionnaire (SF-MPQ) scores to test pain severity, and the Fibromyalgia Impact Questionnaire (FIQ) to test quality of life. Results: The two groups were similar with respect to mean age, body mass index and education status. Algometric pressure pain thresholds of tender point sites were lower in patients with fibromyalgia than in healthy controls. In this patient group, there were linear relations between the number of tender points, duration of pain, SF-MPQ scores, and FIQ. There were also linear relations between duration of pain and SF-MPQ scores and the total number of tender points. Conclusion: In the patient group, all the pain measurements were significantly correlated with each other. The quality of life score was also significantly related to each of the pain parameters. (Turk J Rheumatol 2009; 24: 77-81)

Relationship Between Upper Extremity Muscle Strength and Functional Level and Mobility in Patients with Ankylosing Spondylitis

2009-07-01

Objective: To assess muscle strength of upper extremity muscles in patients with ankylosing spondylitis (AS) and analyze any association between muscle strength and mobility and functional level. Materials and Methods: 30 patients diagnosed as AS and 20 healthy controls were included into the study. Demographics such as age, gender, body mass index, disease duration, and physical activity level were recorded. Mobility parameters [occiput-wall (OWD), chinsternum (CSD), finger-floor distances (FFD), modified Schober (MS), and chest expansion diameter (CED)] were evaluated in both groups. Deltoid anterior, trapezius middle, rhomboid and biceps muscle strength were measured by manual upper extremity-trunk dynamometer. Bath AS Functional Index (BASFI) and Bath AS Disease Activity Index (BASDAI) were used to evaluate functional level. Groups were compared by Mann–Whitney U test. The relationship between muscle strength and mobilization parameters and functional level were analyzed by Spearman correlation coefficient. Results: Mean age of the patients was 34.8�9.1 and the mean disease duration was 8.4�8.3 years (9/21: female/male). The mean age of controls was 34.0�7.3 years (7/13: female/male). All assessed mobilization parameters except CSD and OWD and muscle strengths except rhomboid muscle were significantly lower in patients (p<0.05). In the patient group, biceps muscle strength was associated with MS (r=0.480, p=0.038), CED (r=0.472, p=0.011), and inversely with FFD (-0.628, p=0.000). Middle trapezius muscle strength was associated with MS (r=0.621, p=0.005) and inversely with FFD (r=-0.610, p=0.001). Anterior deltoid muscle strength was associated with MS (r=0.383, p=0.044), CED (r=0.513, p=0.005), and inversely with FFD (r=-0.645, p=0.000) and CSD (r=-0.498, p=0.008). Rhomboid muscle strength was associated with MS, CED (r=0.421, p=0.026), and inversely with FFD (r=-0.504, p=0.006). No correlation was found between measured muscle strength and BASFI and BASDAI scores. Conclusion: Upper extremity muscle strengths decrease in patients with AS. There is an association between upper extremity muscle strengths and mobility. (Turk J Rheumatol 2009; 24: 82-7)

Comparison of Ketoprofen Phonophoresis with Ketoprofen and Lidocaine- Prilocaine Phonophoresis in Patients with Subacromial Impingement Syndrome

Hayal G�ler, Ay�e Dicle Turhano�lu, Kerem �nano�lu, Deniz �nano�lu, Cahit �zer — 2009-07-01

Objective: The aim of the present study was to compare ketoprofen phonophoresis with ketoprofen and lidocaineprilocaine phonophoresis in patients with subacromial impingement syndrome (SIS). Material and Methods: Seventy patients (39 female, 31 male) with SIS were included in this study. The patients were divided into two groups and a 15-session physical therapy and rehabilitation program was performed in each group. Ketoprofen and lidocaineprilocaine phonophoresis were performed in the first group and ketoprofen phonophoresis alone in the second group. Hot pack, transcutaneous electrical nerve stimulation (TENS) and exercises were applied in all patients. Severity of shoulder pain was determined by visual analogue scale (VAS). Range of motion (ROM) was measured by goniometer. Functional capacity of patients was evaluated by UCLA (The University of California-Los Angeles) score. All of the measurements were performed before treatment and in the 1st and 3rd months after treatment. Results: There was no significant difference between the two groups in VAS and UCLA scores before treatment initiation (p>0.05). VAS scores of Group 1 were lower than of Group 2 (p=0.020) in the 3rd month follow-up. ROMs and flexion, abduction and internal rotation were higher in Group 2 than Group 1 (p=0.009, p=0.001, p=0.019, respectively) before treatment. Abduction measurements in Group 2 were higher than in Group 1 in the 1st month after treatment (p=0.024). However, there was no significant difference between the two groups in UCLA and ROM values in the 3rd month (p>0.05). There was also no significant difference between the two groups in external rotation values before and after treatment (p>0.05). Conclusion: Our study showed that ketoprofen and lidocaineprilocaine phonophoresis were more effective on pain and ROM than ketoprofen phonophoresis alone in the 3rd month after treatment in patients with SIS. (Turk J Rheumatol 2009; 24: 88-93)

Osteoarthritis and Glucosamine

Meral Kozak��o�lu — 2009-07-01

Osteoarthritis is the most common form of arthritis and a worldwide health problem. Many institutes and centers have been conducting research studies for years about the advantages of glucosamine sulphate derivatives and chondroitin sulphate on pain and deformities caused by osteoarthritis. The results of the research studies mentioned are discussed in this paper. The controlled, randomized, double blind research studies have shown chondroitin sulphate to have good symptomatic effects on osteoarthritis, although some controversies remain. New research studies have revealed that glucosamine sulphate and chondroitin sulphate both have a suppressor effect on the structural deformities of osteoarthritis. (Turk J Rheumatol 2009; 24: 94-7)

Neuroendocrine Dysfunction in Fibromyalgia

�zlem Alt�nda� — 2009-07-01

Fibromyalgia is a chronic rheumatismal disease characterized by widespread pain and fatigue with unknown etiology. Subtle alterations of the neuroendocrine system in fibromyalgia syndrome have been proposed as a shared pathway linking numerous etiological and perpetuating processes with symptoms and observed physiological abnormalities. The role of neurohormonal mechanisms in the pathogenesis of fibromyalgia is discussed in this paper. (Turk J Rheumatol 2009; 24: 98-102)

Complex Regional Pain Syndrome Type 1 in Both Lower Extremities, Resistant to Treatment: A Case Report

�zlem Alt�nda�, Ali Aydeniz, Sava� G�rsoy, T�rkan Harunlar Bukan — 2009-07-01

Complex regional pain syndrome type 1 (CRPS-1) is characterized by pain, vasomotor and sudomotor changes and trophic disturbances. It may develop as a result of trauma, especially extremity fractures and surgery. Although the pathogenesis of CRPS-1 is not exactly clear, abnormal sympathetic nerve activity may be a potential etiological factor. Occurrence of CRPS-1 in the lower extremity with bilateral involvement is a very rare condition. Calcitonin, bisphosphonates and analgesics can be used in the management of these cases. A case of bilateral lower extremity CRPS-1 with rebellious pain is described and discussed in this paper. We suggest bilateral CRPS-1 may occur in the lower extremity and pregabalin may be an effective and alternative therapy in these patients. (Turk J Rheumatol 2009; 24: 103-5)

Overlap of Multiple Sclerosis and Antiphospholipid Syndrome

�brahim Tekeo�lu, Temel Tombul, �zcan H�z, Elif G�lc�, Murat Toprak — 2009-07-01

Antiphospholipid syndrome (APS) and multiple sclerosis (MS) are two diseases that may show similar clinical and radiological findings and sometimes cause confusion. In the presence of thrombosis, repetitious abortion history, and lupus anticoagulant antibodies or anticardiolipin antibodies, APS should be considered. However, in previous studies, autoantibody levels were detected as being high in MS patients when compared to the normal population. Laboratory study of a patient with fever, fatigue, joint pain and cyanosis in the ankles since 1995 and history of two abortions at 6 weeks gestation revealed: C-reactive protein: (++++), erythrocyte sedimentation rate: 70 mm/hour, antinuclear antibodies: 1/1000 homogeneous, and LE cell positivity. Brain magnetic resonance imaging, visual evoked potantial, somatosensorial evoked potential, and oligoclonal band investigations of the patient, who applied to the Neurology Clinic of the hospital in 1999 with complaints of disruption in walking, imbalance and fatigue, were found compatible with MS. The patient had suffered from recurrent attacks and had been directed to our clinic with probable diagnosis of systemic lupus erythematosus when pain in knees and macular style skin lesion on the right ankle finally developed in 2007. Investigations conducted at six-month time intervals revealed anticardiolipin IgG: positive, anticardiolipin IgM: negative and antinuclear antibody (ANA): positive. When ANA and anticardiolipin IgG positivity and abortion history of the patient were evaluated together, APS accompanying MS was diagnosed and 100 mg aspirin was added to the treatment. In conclusion, MS and APS can not only appear together but may also imitate each other. Thus, cases diagnosed as MS should be carefully evaluated in terms of clinical and laboratory findings of APS. (Turk J Rheumatol 2009; 24: 106-9)

A Psoriatic Arthritis Case with Skin Manifestations Occurring 20 Years After the Arthritis

Filiz Eser, Hatice Bodur, �mit Se�kin, P�nar Ero�lu — 2009-07-01

Psoriatic arthritis (PsA) is an inflammatory arthritis in the spondyloarthropathy group. The variety of the clinical findings, lack of diagnostic criteria, potential conflicting syndromes, and the possibility of joint involvement before the skin involvement make the diagnosis more difficult. In 15-20% of the cases with PsA, it is reported that the lesions start after the arthritis. Here, we present a 59-year-old female patient with PsA, whose skin manifestations were diagnosed 20 years after the arthritis. She had symmetrical polyarthritis on her hand joints and had been followed up with the diagnosis of seronegative RA. (Turk J Rheumatol 2009; 24: 110-2)

Diastematomyelia - A Case Report

Ayten T�rcan, Saadet Yazgan Umut, Mustafa Akif Sar�y�ld�z — 2009-07-01

Diastematomyelia - a congenital anomaly accompanied by multiple skeletal anomalies - is characterized by division of the neural chest into two. With somatic growth over an adult's lifetime, it might cause back pain, waist pain and neurological symptoms due to a strained cord. (Turk J Rheumatol 2009; 24: 113-5)

Baker's Cyst: Letter to the Editor

Sami Karapolat — 2009-07-01