Fatma Inanici

Ultrasonographical evaluation of the Achilles’ tendon in psoriasis patients

Background  Psoriasis is a common dermatological disease with erythematous plaques where articular and extra articular findings (tenosynovitis and enthesitis) may well accompany. The aim of this current study was to evaluate the Achilles’ tendon of psoriasis patients with ultrasonography.

Quantification of the weakness and fatigue in thoracic outlet syndrome with isokinetic measurements

Objectives: Patients with thoracic outlet syndrome (TOS) complain of many subjective symptoms that are difficult to measure and quantify. In this study we have tried to assess the weakness (muscle strength) and fatigue (endurance) of these patients with an objective measurement method, isokinetic muscle testing. Methods: Twenty three TOS patients and 15 age matched healthy controls were enrolled in the study. Detailed histories of the patients were taken and the patients underwent complete physical examinations. Cervical radiographies, Doppler ultrasonography, electromyography, and isokinetic measurements were carried out. The isokinetic measurements were carried using the Biodex System 3 dynamometer during concentric shoulder flexions and extensions at velocities of 60°/s, 180°/s, and 240°/s. Results: Although the muscle strengths of both groups seemed to be similar, the fatigue ratios of TOS patients at 60°/s and 180°/s were found to be higher compared with those of healthy controls (p = 0.029, p = 0.007). Conclusions: TOS patients were found to have muscular performance similar to controls, but their upper extremities developed fatigue more easily than those of healthy individuals.

Urinary neopterin excretion and dihydropteridine reductase activity in rheumatoid arthritis

Abstract Neopterin and biopterin are two products of the pteridine pathway. Even though their roles and interrelationships have not been exactly clarified, neopterin is known as a biomarker of cell-mediated immunity. In this case, the highly elevated neopterin levels are parallel to the slightly elevated biopterin levels. On the otherhand, the reduced form of biopterin-tetrahydrobiopterin is an essential cofactor of aromatic monoxygenases that leads to synthesis of tyrosine, tryptophan and dopamine neurotransmitters and its concentration in body fluids and tissues is maintained by the enzyme dihydropteridine reductase (DHPR). Increased numbers of activated lymphocytes can be found in peripheral blood, in the synovial fluid and synovial membranes or patients with rheumatoid arthritis (RA). Since the present study was undertaken to evaluate the role of the pteridine pathway in RA, we measured urine neopterin levels and dried blood DHPR activities in 36 patients with RA and in 20 healthy volunteers, in parallel with other clinical parameters. We found that neopterin excretion was significantly increased in RA patients compared with controls. The means were 433±216, 153±43 and 111±34 μmol/mol creatinine for patients in active stage, in remission and controls, respectively. Our results suggest that urine neopterin levels were strongly dependent on the stage and activity of RA. Either as an effect of the disease itself or of drug administration, slightly reduced DHPR activities were detected (3.484± 0.304 for control, 2.974±0.255 in active stage RA, and 3.048±0.302 red cytochrome C/min/5 mm disc in remission).

Tender Point Injections Are Beneficial in Fibromyalgia Syndrome: A Descriptive, Open Study

Objective: Efficacy of tender point [TeP] injections in fibromyalgia syndrome [FMS] has not been well described in the literature. The goal of our study was to determine the extent of benefit from such injections in this syndrome in the usual clinical practice setting. Methods: Tender points at most symptomatic sites of forty-one patients with FMS, 40 females and one male, were injected with a mixture of 1/2 ml 1% lidocaine and 1/4 ml intralesional triamcinolone diacetate suspension, and prospectively followed for a mean period of 66 [range 14–240] weeks. All patients were asked to maintain a diary to record the duration of pain relief from injections. They continued their usual therapies. Results: On an average, 3.97 injections per visit were performed. Mean duration of pain relief per injection site was 13.1±9.4 weeks, excluding a single outlier patient. Only one patient failed to obtain any relief at any injected site. There were no side-effects with the exception of a brief postinjection flare in one patient. No demographic or clinical variables at initial consultation were associated with duration of pain relief, with the exception of anxiety and depression scores, which were negatively correlated [P < 0.001]. Conclusion: Our prospective but open study demonstrates that TeP injections are a useful and safe adjunct to other forms of therapy in FMS. However, further studies in the future are indicated.

Yoga therapy and ambulatory multiple sclerosis Assessment of gait analysis parameters, fatigue and balance.

BACKGROUND AND OBJECTIVE Gait impairment, falls due to balance problems and fatigue are among the most important complaints in patients with multiple sclerosis (MS) and cause significant functional limitation. Use of complementary and alternative medicine (CAM) to help symptom management and to improve quality of life is growing among MS patients. Yoga is widely used as one of these CAM interventions, however, the number of studies that show the efficacy of yoga training in MS is inadequate. In this study, we aimed to evaluate the effects of a short term yoga program on fatigue, balance and gait in patients with MS. METHOD Eight volunteer ambulatory MS patients with clinically definite relapsing remitting MS whose Expanded Disability Status Score (EDSS) is less than or equal to 6.0, and eight healthy subjects were included in the study. Patients participated in 12 weeks of a bi-weekly yoga program under supervision. At their baseline and after yoga therapy, the Fatigue Severity Scale (FSS) and Berg Balance Scale (BBS) are used to assess fatigue and balance. Three dimensional gait analysis is done using the Vicon 612 system with six cameras and two Bertec force plates, before and after therapy. RESULTS After short term yoga therapy, statistically significant achievements were obtained in fatigue, balance, step length and walking speed. Although sagittal plane pelvis and hip angles, ankle plantar flexor moment, powers generated at the hip and ankle joints at the pre-swing were improved, the improvements were not statistically significant. CONCLUSION Yoga therapy is a safe and beneficial intervention for improving fatigue, balance and spatiotemporal gait parameters in patients with MS. Further studies with a larger sample size and longer follow-up will be needed to evaluate the long term effects of yoga therapy.

Knee muscle strength in multiple sclerosis: relationship with gait characteristics

[Purpose] To investigate the relationship between isokinetic knee muscle strength and kinematic, kinetic and spatiotemporal gait parameters of patients with multiple sclerosis (MS). [Subjects and Methods] Twenty-nine MS patients (mean age 31.5±6.5) were investigated in this study. The isokinetic knee muscle strength and gait parameters of MS patients with moderate and severe disability, as determined by the expanded disability status scale (EDSS): EDSS=1–4.5 (n=22, moderate disability) and EDSS>4.5 (n=7, severe disability) were measured. [Results] Isokinetic knee muscle strength, kinematic, kinetic and spatiotemporal gait parameters differed between moderate (EDSS=1–4.5, n=22) and severe disability (EDSS>4.5, n=7). The correlation between each of gait speed, stride length, total range of knee joint movement and the four strength parameters (minimum and maximum quadriceps and hamstring muscle strengths) were significant for the MS group as a whole. Within subgroups, the correlation between minimum hamstring strength and total range of knee movement was significant only in group EDSS>4.5; minimum hamstring correlated with peak knee extensor moment in group EDSS=1–4.5, but at a reduced level of significance. [Conclusion] The present study revealed significant correlations between gait characteristics and isokinetic strength parameters of the quadriceps and hamstring muscles. Our study suggests that rehabilitation protocols for MS patients should include a critical strength training programme particularly for the hamstring and quadriceps muscles.

The frequency of fibromyalgia in sport professionals

Fibromyalgia is a chronic musculoskeletal disorder characterized by widespread pain and tenderness at specific anatomic sites, commonly accompanied by fatigue [1]. The etiopathogenesis of fibromyalgia is probably multifactorial and peripheral, and central factors are thought to interact with the development of this syndrome. The true incidence and prevalence of fibromyalgia is unknown. However, studies from North America and Europe have revealed overall prevalence rates ranging from 1 to 5% in the general population [2]. It is well known that many individuals with fibromyalgia are typically inactive and deconditioned [3, 4]. Thus, various forms of exercises are increasingly recommended to these patients as an integral part of nonpharmacological treatment. Aerobic and muscle strengthening exercises are shown to be effective at improving symptoms, tender point counts, pain threshold, physical fitness and quality in fibromyalgia [5]. Professional athletes regularly perform exercise programs designed to improve and maintain their physical fitness. Therefore, it can be expected that the prevalence of fibromyalgia in adults participating in competitive sports is to be lower than that in general population. The aim of this study was to determine the frequency of fibromyalgia in a population of sport professionals. One hundred and eighty-five sport professionals (74 women, 111 men) were enrolled in the study. Each of the participants was asked whether he or she had widespread pain over the last 3 months. If the answer was yes, then the duration and severity of pain were recorded. In the physical examination, 18 tender points identified by the 1990 American College of Rheumatology (ACR) criteria for the diagnosis of fibromyalgia were palpated, and the subjects’ responses were noted. Statistical analyses were performed by using the SPSS version 11.5 for Windows package program. Results were expressed as mean ± standard deviation. Mann–Whitney U test was used for comparison of the duration and severity of pain. Statistical significance was determined at P value \ 0.05. Fifty-nine participants (64.4% of them were men) with a mean age of 23.9 ± 4.9 years had declared that they have widespread pain. The mean duration of pain was 37.8 ± 39.3 (median 24) months. The mean value of pain severity marked on a 10-cm visual analog scale was 42.5 ± 21.2 mm. There were no significant differences between genders in the duration and severity of widespread pain. Six of the individuals with widespread pain had no tender points, whereas the average number in the ones who had at least one tender point was 5.5 ± 3.7 (1–18). Eleven or more of the 18 tender points were detected in 12 subjects. However, only 4 of them suffered from widespread pain and diagnosed with fibromyalgia. To the best of our knowledge, only one study has been previously conducted to determine the prevalence of fibromyalgia in young healthy athletes. Andary et al. evaluated 641 college student athletes and found that only F. _ Inanici O. Ozdemir Y. G. Kutsal Z. Hascelik Department of Physical Medicine and Rehabilitation, Hacettepe University Medical School, Ankara, Turkey

In vivo effects of non-steroidal antiinflammatory drugs on oxidative stress-related parameters of human erythrocytes*

In this study, we evaluated the effects of commonly used non-steroidal anti-inflammatory drugs (NSAIDs) on oxidative stress and anti-oxidant system. Sixteen healthy volunteers and 35 patients diagnosed as one of musculoskeletal disorders were included in the study. Patients were treated with one of the three NSAIDs (i.e. naproxen, tiaprofenic acid, acemetacin) or paracetamol for 15 days. Erythrocyte glutathione S-transferase, erythrocyte and plasma glutathione peroxidase, and erythrocyte catalase (CAT) activities and plasma malondialdehyde level as lipid peroxidation index were detected in the blood samples of the patients, at the beginning of the study (0 week), after treatment for 15 days (2nd week), and at the end of 1 week-washout period (3rd week). The most affected enzyme by NSAIDs was erythrocyte catalase, which tended to increase at the end of 2 weeks treatment, and decrease at the end of 1 week-washout period. In the groups treated with acemetacin, naproxen and tiaprofenic acid, plasma malondialdehyde levels were decreased at some extent, but at the end of washout period a rebound increase was observed in acemetacin group. Our results suggest that NSAIDs have different influences on oxidative stress and anti-oxidant system related parameters. These effects seem to be related with the mechanisms of some of the adverse effects, which are not well understood yet. Further studies with larger groups are needed to illuminate the relationship between adverse effects of NSAIDs and the effects of these drugs on anti-oxidant system, and to clarify their mechanisms of therapeutic action, as well.

Hand Strengths in Carpal Tunnel Syndrome

The purpose of this study was to determine whether a measurable decrease in isokinetic (dynamic) and isometric (static) hand strengths occurs in carpal tunnel syndrome (CTS) patients. Eighteen CTS patients and 20 healthy controls were included in the study. Isokinetic (eccentric and concentric) and isometric grip and pinch strengths were measured with a Biodex System 3 dynamometer (Biodex Medical System, Inc. New York). All strength measurements, except isometric and isokinetic (concentric/eccentric) three-point pinch and isokinetic (concentric) tip pinch, revealed statistically significant differences between CTS patients and controls. Measurable decrease in hand strengths may exist in CTS despite normal manual assessments. Although both isokinetic (dynamic) and isometric (static) dynamometers are capable of detecting this decrease, neither technique seems better than the other.

Magnetic resonance imaging: a sine qua non in the diagnosis of brucella spondylitis

Brucellosis is an endemic disease –primarily a zoonosis – contracted from infected animals that is closely linked to poor methods of animal husbandry, feeding habits and standards of hygiene [1]. Osteoarticular complications are well known to exist in large or medium-sized peripheral joints, the sacroiliacs and the spine [2, 3], whereas clinical manifestations are unspecific and warrant diligent investigations for the purpose of diagnosis [1, 4]. Also, they may masquerade as different clinical entities [2, 3, 4]; prompt diagnosis is therefore genuinely crucial owing to their high prevalence and associated functional sequelae. We here present a case in which this challenging clinical scenario was experienced. A 43-year-old man was seen with the complaint of low back pain for the last 3–4 months. He declared that the pain was also radiating to his right lower limb. He denied having any paresthesias, but described the pain as increasing during coughing. His past history was noncontributory except for an episode of brucellosis 4 months ago that had been treated with 6-weeks’ antibiotic therapy –a combination of rifampicin and ofloxacin. His physical examination revealed limited lumbar motion and bilateral paravertebral muscle spasm, and the straight leg raising test was found to be painful at 45 on the right side without any neurological deficit. Brucella agglutination tests and blood cultures were both negative. Radiographs of the sacroiliac and lumbar regions (including oblique views) did not yield any relevant pathologies (Fig. 1). Bearing in mind the possible spondylitic complications of brucellosis and the lack of conventional radiographs in delineating them, we considered an onward magnetic resonance imaging (MRI) study to be necessary and quite reasonable for clarifying the exact underlying cause of our patient’s low back pain. MRI study demonstrated small protrusions at L2–L3, T11–T12 disc levels and depicted the L4–L5 spondylodiscitis as follows: posterocentral and right paramedian soft tissue compressing the right neural foramen at this leel, also extending along the L4–S1 anterior epidural space with a hypointense central necrotic area (Fig. 1). The patient was then referred to the infectious diseases department with the above-mentioned diagnosis. The spondylodiscitis was considered to be healing in the chronic stage, and so he was prescribed controls with no other active infection findings. Lumbar vertebrae are the most commonly involved segments once brucella spondylitis ensues [2]. Accordingly, spinal cord or spinal root compressions –reminiscent of lumbar disc herniations – can eventually be seen during the course of the ongoing inflammatory process [1, 3, 4]. This entails a prudent clinical approach in patients with an antecedent brucellosis. Fortunately, in our patient, we knew the previous diagnosis and it