Figen Ayhan

The short-term efficacy of laser, brace, and ultrasound treatment in lateral epicondylitis: a prospective, randomized, controlled trial.

The aims of this study were to evaluate the effects of low-level laser therapy (LLLT) and to compare these with the effects of brace or ultrasound (US) treatment in tennis elbow. The study design used was a prospective and randomized, controlled, single-blind trial. Fifty-eight outpatients with lateral epicondylitis (9 men, 49 women) were included in the trial. The patients were divided into three groups: 1) brace group-brace plus exercise, 2) ultrasound group-US plus exercise, and 3) laser group-LLLT plus exercise. Patients in the brace group used a lateral counterforce brace for three weeks, US plus hot pack in the ultrasound group, and laser plus hot pack in the LLLT group. In addition, all patients were given progressive stretching and strengthening exercise programs. Grip strength and pain severity were evaluated with visual analog scale (VAS) at baseline, at the second week of treatment, and at the sixth week of treatment. VAS improved significantly in all groups after the treatment and in the ultrasound and laser groups at the sixth week (p<0.05). Grip strength of the affected hand increased only in the laser group after treatment, but was not changed at the sixth week. There were no significant differences between the groups on VAS and grip strength at baseline and at follow-up assessments. The results show that, in patients with lateral epicondylitis, a brace has a shorter beneficial effect than US and laser therapy in reducing pain, and that laser therapy is more effective than the brace and US treatment in improving grip strength.

Foot Problems in a Group of Patients with Rheumatoid Arthritis: An Unmet Need for Foot Care

Objectives: The aim of this study was to evaluate the foot involvement in a group of RA patients in regard to symptoms, type and frequency of deformities, location, radiological changes, and foot care. Patients and Methods: A randomized selected 100 rheumatoid arthritis (RA) patients were recruited to the study. Data about foot symptoms, duration and location of foot pain, pain intensity, access to services related to foot, treatment, orthoses and assistive devices, and usefulness of therapies were determined by the questionnaire. Radiological changes were assessed according to modified Larsen scoring system. The scores of disease activity scale of 28 joints and Health Assessment Questionnaire indicating the functional status of RA patients were collected from patient files. Results: A total of 100 RA patients (90 female, 10 male) with a mean age of 52.5 ±10.9 years were enrolled to the study. Eighty-nine of the 100 patients had experienced foot complaints/symptoms in the past or currently. Foot pain and foot symptoms were reported as the first site of involvement in 14 patients. Thirty-six patients had ankle pain and the most common sites of the foot symptoms were ankle (36%) and forefoot (30%) followed by hindfoot (17%) and midfoot (7%) currently. Forty-nine of the patients described that they had difficulty in performing their foot care. Insoles and orthopedic shoes were prescribed in 39 patients, but only 14 of them continued to use them. The main reasons for not wearing them were; 17 not helpful (43%), 5 made foot pain worse (12.8%), and 3 did not fit (7.6%). Foot symptoms were reported to be decreased in 24 % of the subjects after the medical treatment and 6 patients indicated that they had underwent foot surgery. Current foot pain was significantly associated with higher body mass index and longer disease duration, and duration of morning stiffness. The radiological scores did not correlate with duration of foot symptoms and current foot pain (p>0.05) but the total number of foot deformities was found to be correlated with Larsen scores (p<0.05). Conclusion: In our study, foot involvement and foot symptoms were seen frequently in RA but there is an unmet need for provision and monitoring of foot care in patients suffering from this chronic disease.

Fibromyalgia Syndrome: Is It Related to Vitamin D Deficiency in Premenopausal Female Patients? ---

There are a number of studies that have evaluated the relationship between fibromyalgia (FM) and vitamin D deficiency with conflicting results. The aim of this study was to assess vitamin D deficiency in patients with FM and to evaluate the relationship with the common symptoms of FM and levels of serum vitamin D. Forty premenopausal female fibromyalgia patients and 40 age- and sex-matched control subjects were included in the study. The demographic characteristics of all subjects, including age, sex, and body mass index, were recorded. The number of tender points was recorded, and the intensity of the widespread pain of the subjects was measured by the visual analog scale. The activities of daily living component of the Fibromyalgia Impact Questionnaire (FIQ-ADL), was used to assess physical functional capacity. Serum vitamin D was measured in both groups, and vitamin D levels <37.5 nmol/L were accepted as vitamin D deficiency. The vitamin D levels and clinical and laboratory characteristics of the patient and control groups were comparatively analyzed. The relationship between vitamin D levels and clinical findings of the FM patients were also determined. The mean age was 41.23 ± 4.8 and 39.48 ± 4.08 years for the patient and control groups, respectively. The pain intensity, number of tender points, and FIQ-ADL scores were higher in FM patients than in control subjects. The mean levels of vitamin D in the patient and control groups were determined to be 31.97 ± 15.50 and 28.97 ± 13.31 nmol/L, respectively (p > .05). The incidence of vitamin D deficiency was similar between the patient and control groups (67.5% vs. 70%). Vitamin D levels significantly correlated with pain intensity (r = -0.653; p = .001) and FIQ-ADL scores in the FM group (r = -0.344; p = .030). In conclusion, the results of this study indicate that deficiency of vitamin D is not more common in premenopausal female patients with FM than in control subjects without FM. However, the association between pain and vitamin D levels in FM patients emphasizes that hypovitaminosis of vitamin D in the FM syndrome may have an augmenting impact on pain intensity and functional status. Future studies are needed to show the effect of vitamin D supplementation in the reduction of pain intensity and disability in patients suffering from this chronic condition.

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

Abstract 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.

Erosive wrist and hand arthritis: is it a rare manifestation of Behçet's disease?

It is believed that arthritis in Behçet’s disease is usually non-erosive and non-destructive. We report herein a 72-year-old female who presented with Behçet’s disease and an erosive arthritis of the bilateral elbow, wrist, and metacarpophalangeal and proximal interphalangeal joints, radiologically mimicking rheumatoid arthritis.

The inadequate anti-tumour necrosis factor (anti-TNF) therapy in patients with ankylosing spondylitis

Dear editor, Ankylosing spondylitis (AS) is a chronic progressive inflammatory disease of axial and peripheral joints associated with serious disability and a significant reduction in quality of life [1]. The prevalences of AS and related spondyloarthritis in most of the Meditterenean countries including ours have been determined as 0.5–1% and seems to be higher than the observed prevalences in other countries [2, 3]. Until recently, delayed diagnosis was common, due to insensitivity of traditional radiographs and treatment strategies were limited to NSAIDs, DMARDs and physical therapy interventions. However, conclusive evidence for the efficacy of these drugs with respect to axial disease is still lacking. The introduction of tumour necrosis factor (TNF) blocking drugs has remarkably changed the treatment options and clinical progression of this condition. Although the guidelines for introducing anti-TNF agents in patients with AS has been defined, there is still a doubtful approach to optimal use of these agents and there exists an unmet need for anti-TNF therapy in AS patients [2, 4, 5]. We have retrospectively determined the demographical and clinical characteristics of AS patients following at our rheumatology outpatient unit and evaluated the current therapies as well as the disease activity status. The demographical variables including age, sex, occupation, disease duration, axial, and peripheral involvement were determined. The current BASDAI, BASFI, BASMI, and pain intensity assessed by VAS were also recorded. For BASDAI, the cut off limit was accepted as four for active disease. A total of 103 AS patients (80 male,23 female) with a mean age of 39.6 ± 12.4 years (18–78) were enrolled to the study. The male/female ratio was 34.7. The mean disease duration was 12.7 ± 9.5 years. Regarding occupational status 65 (63.1%) were employed, 15 (14.5%) were housewifes and 12 (11.6%) were retired, while 11 (10.6%) were unemployed. The ratios of axial, peripheral and both involvements were 97.2, 46.4, and 28.8%, respectively, in our patient group. The mean values of pain by VAS, BASDAI, BASMI, and BASFI were 5.8 ± 2.6, 3.54 ± 2.1, 4.8 ± 3.2, and 3.8 ± 2.2, respectively. The rate of patients with BASDAI [4 was 39.8%. The percentage of patients using NSAID was 89.4%, salazopyrine 71.9%, methotrexate 1.9% and the ratio of antiTNF medication was 8.7%. In this retrospective analysis, we indicated a high disease activity and inadequate therapy for most of our patients with AS, being followed at a big tertiary reference hospital in the capital of a developing country. Almost half of the patients met the recommended criteria for anti-TNF therapy, but only 8% patients were using anti-TNF drugs. Conventional therapies rather than biological therapies were common in our patient group. Most of our patients were working, but had an acitivity limitation. Our results are in accordance with a recent study evaluating patients from different parts of the same country [2]. Almost 10 years after the introduction of anti-TNF agents for the treatment of AS, physicians are still struggling with their appropriate use. Several factors may contribute to these results. The cost of these new agents, economic considerations, safety issues, patient concerns regarding side effects and toxicities, the absence of predictive markers of response and difficulty of careful monitorization in some centers, have prevented their use in demand and unabled to give the appropriate treatment. In conclusion, awareness of the disease activity and the unmet P. Borman (&) F. Ayhan E. Ceceli Ankara Training and Research Hospital, Clinic of PMR, Cebeci, Ankara, Turkey e-mail: pinarb@ato.org.tr