Fitnat Dinçer

EULAR evidence-based recommendations for the management of fibromyalgia syndrome

Objective: To develop evidence-based recommendations for the management of fibromyalgia syndrome. Methods: A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords “fibromyalgia”, “treatment or management” and “trial”. Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation. Results: 146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and “other pharmacological” and exercise, cognitive behavioural therapy, education, dietary interventions and “other non-pharmacological”. In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made. Conclusions: Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

EULAR revised recommendations for the management of fibromyalgia

Objective The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were ‘expert opinion’. Methods A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations. Results 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only ‘strong for’ therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as ‘weak for’ based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability). Conclusions These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

Bone Mineral Density in Children with Juvenile Chronic Arthritis

The aim of this study was to evaluate bone mineral density changes in patients with juvenile chronic arthritis (JCA) and to determine the most likely causes of osteoporosis in these patients. Eighteen (11 male, 7 female) patients suffering from JCA and 14 healthy controls (10 male, four female) were included in this study. The mean age of the patients and control groups were 11.0±3.2 and 10.9±2.9 years respectively. Disease activity was determined by clinical and laboratory evaluation and ‘Articular Disease Severity Score’ (ADSS). Bone mineral density (BMD) of the femoral neck and lumbar spine was measured by dual photon absorptiometry.BMD of the patients at the lumbar spine was significantly lower than the control group (p<0.05). This difference was more marked in patients treated with steroids. Femoral neck BMD was also lower in the patient group but this difference was not statistically significant. There was a negative correlation between ADSS and BMD at the spine. In conclusion, trabecular bone loss is characteristic for osteoporosis in JCA. Our results indicate that steroid treatment and disease severity are important factors in the development of osteoporosis in JCA.

Rehabiliation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques

Çetin A, Dinçer F, Keçik A, Çetin M: Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques. Am J Phys Med Rehabil 2001;80:721–728. Objective: Kleinert (active extension, rubber-band passive flexion) and Duran (passive extension, passive flexion) protocols are two basic types of early motion programs for rehabilitation of flexor tendon injuries. Researchers have been working on various modifications or combinations of these two protocols to improve rehabilitation results. The purpose of this study was to analyze the quality of the functional results of flexor tendon repair after a postoperative regimen of early mobilization by use of a combined regimen of modified Kleinert and modified Duran techniques. Design: Thirty-seven patients (74 digits) with repaired flexor tendon injuries were treated. Functional results of the fingers were evaluated by the Buck-Gramcko system and total active motion measurements. Results: The results were excellent in 73% of the fingers, good in 24%, fair in 1.5%, and none was rated poor. Conclusion: Our results are comparable with the previous studies that used various postoperative rehabilitation techniques. This postoperative management provides an effective way of achieving satisfactory results. Patient-assisted passive exercises are very safe and more cost effective than therapist-assisted passive exercises.

Factors playing a role in the development of decreased bone mineral density in juvenile chronic arthritis

ObjectiveThe aims of this study were to evaluate bone mineral density (BMD) in patients with juvenile chronic arthritis (JCA), compare them with healthy controls, and assess the effects of disease activity and corticosteroid treatment on BMD.MethodsTwenty-eight patients diagnosed with JCA and 45 healthy controls were included in this study. Disease activity was determined by clinical and laboratory evaluation, Articular Disease Severity Score (ADSS), and the Juvenile Arthritis Functional Assessment Report (JAFAR). Bone mineral density of the lumbar spine was measured by dual energy X-ray absorptiometry (DEXA).ResultsPatients with JCA showed significant decreases in BMD compared with healthy controls. The JCA patients treated with corticosteroids showed significantly lower BMDs than the healthy control group. Age of the patients and age of onset were found to correlate with BMD.ConclusionOur study showed that glucocorticoids were involved in the development of osteoporosis in JCA, with many other factors affecting bone mineralization. We could not demonstrate any relationship between BMD and disease activity, but the study data suggest that early onset disease is also an important factor in the development of osteoporosis in JCA.

Psychosocial function, clinical status, and radiographic findings in a group of chronic low back pain patients

Abstract. Low back pain is considered a problem with multiple facets for which the underlying causative factors should be determined. The aim of this study was to evaluate the relationships between depression, clinical status, and radiographic findings in a group of fifty patients with low back pain for more than 6 months. The patients underwent clinical examination and they completed Beck depression inventory (BDI), Aberdeen back pain scale (ABPS) and research questionnaire. Radiographic evaluations were performed. Clinical score and duration of symptoms were found to be positively correlated. The BDI scores were not found to be correlated with the existing variables. The ABPS scores were positively correlated with clinical scores and number of medications used.

Evaluation of Chronic Plantar Fasciitis by Scintigraphy and Relation to Clinical Parameters

Objectives: Chronic plantar fasciitis is a clinical condition characterized by pain and tenderness localized to the plantar surface of the heel. Patients with plantar fasciitis have very few findings on physical examination. The aim of this study was to document the frequency of abnormalities seen in scintigraphic images from patients with chronic heel pain and a control population, and to correlate scintigraphic findings with clinical parameters. Methods: Twenty-two patients [17 female and five male] with chronic heel pain were included in this cross-sectional study. The control group consisted of 17 [nine female, eight male] subjects with no history of heel pain who were referred for a bone scan for other nonpedal conditions. Daily standing times of each subject were recorded and body mass index of the study subjects were measured. Heel pain of the patients at rest and on weight bearing were evaluated using a 10 point visual analog scale. All patients were scanned after intravenous injection of Tc-99 m methylene diphosphonate. Results: Bone scans of 16 of the 22 patients with heel pain showed increased uptake at the medial calcaneal tubercle. However, scan findings of the control group were normal. There were no differences between patients and controls as to age, body mass index, and daily standing time. Conclusions: It is concluded that plantar fasciitis is a common cause of heel pain and the bone scan is a simple and convenient method for diagnosing plantar fasciitis.

EULAR recommendations for management of fibromyalgia

The EULAR recommendations for the management of fibromyalgia are based on more than 100 reviews and meta-analyses of individual therapies and medicines.1 Thus, the quality of the evidence in making recommendations on effectiveness and efficacy is generally very high. In contrast, there is little published research …

Physical Examination of the Hand

Thorough physical examination of the hand is crucial in the assessment of hand functions. In this chapter, physical examination of the hand including general inspection, palpation, range of motion assessment of each joint, neurologic examination, and evaluation of the hand’s vascular supply is reviewed in details. Furthermore, the specific tests for carpal tunnel syndrome, Wartenberg’s syndrome, ulnar nerve compression syndromes, and de Quervain’s tenosynovitis are also described. Once the patient enters the room, the clinical examination begins with inspection followed by the palpation of not only soft tissue and bony structures of hand but also the whole upper extremity. Range of motion measurement of the wrist, fingers, and thumb by using a goniometer is an essential component of hand function evaluation. Besides motor and sensory function assessment which is especially important in traumatic hand injuries, the specific tests for the common hand pathologies such as Tinel’s sign and Phalen’s and Finkelstein’s test should be also performed to make an accurate differential diagnosis.

The effect of isokinetic and aerobic exercises on serum interleukin-6 and tumor necrosis factor alpha levels, pain, and functional activity in patients with knee osteoarthritis.

Objectives. The aim of this study is to investigate the effects of isokinetic and aerobic exercise training programs on serum pro-inflammatory cytokine levels, pain, and functional activity in patients with knee osteoarthritis (OA). Methods. Forty-two postmenopausal women and men with knee OA according to American College of Rheumatology diagnostic criteria were included. Patients were randomized into isokinetic and aerobic exercises and control groups. In intervention groups, patients were included in predetermined exercise programs 3 times per week for 6 weeks. Severity of pain, functional activity status, muscle strength, functional capacity, and serum cytokine levels were evaluated at baseline and at the 6th week. Results. At the end of 6th week, there was no statistically significant decrease in serum pro-inflammatory cytokine levels in both the exercise groups, although C-reactive protein levels exhibited a strong trend toward significance. We found a significant decrease in visual analog scale and Western Ontario McMaster Osteoarthritis Index scores, and significant increase in functional capacity and muscle strength in both the exercise groups compared with those in the control group.