Nurettin Tastekin

The evaluation of quality of life in fibromyalgia syndrome: a comparison with rheumatoid arthritis by using SF-36 Health Survey

Musculoskeletal disorders are the most common causes of deterioration in quality of life (QOL). We in this study aimed to assess (1) the impact of fibromyalgia syndrome (FS) on QOL comparing with that of rheumatoid arthritis (RA) patients and control subjects and (2) the impact of these two musculoskeletal disorders on various components of QOL using SF-36 Health Survey. Thirty-five patients with RA, 30 patients with FS, and 30 voluntary control subjects were included in the study. The groups were comparable in terms of demographic characteristics. QOL was evaluated by using Short-Form (SF)-36 Health Survey in all study participants, and Fibromyalgia Impact Questionnaire (FIQ), which is a specific health-status instrument for FS, was used in FS patients. Physical functioning, physical role, social functioning, bodily pain, general health, vitality, emotional role, and mental health scores were significantly lower in RA and FS patients than in control subjects (p<0.05). The between-groups comparisons revealed that FS patients had significantly lower mental health scores than RA patients (49.87 vs 62.51, respectively), (p<0.001). Total FIQ score correlated significantly with physical functioning, physical role, and bodily pain in FS patients. All parameters of SF-36 Health Survey except for social functioning correlated significantly with some of the variables of FIQ. FS has a negative impact on QOL, like RA. Furthermore, mental health was more severely affected in FS patients when compared with RA patients.

Pedobarography and its relation to radiologic erosion scores in rheumatoid arthritis

ObjectiveThe aim of this study was to assess probable plantar pressure alterations in rheumatoid arthritis (RA) patients by comparison with normal subjects and to investigate the probable relation between pressure distribution under the foot and radiologic foot erosion score.MethodsTwo hundred feet of 50 chronic RA patients and 50 healthy controls were evaluated. Static and dynamic pedobarographic evaluations were used to define the plantar pressure distribution. Also, the modified Larsen scoring system was used to detect the staging of erosions on feet radiograms of the RA patients.ResultsStatic pedobarography revealed higher pressure and contact areas in the forefoot. All dynamic pedobarographic parameters except for plantar contact area were significantly different between the RA patients and control subjects. Patients with high erosion scores had higher static forefoot and dynamic phalanx peak pressure values.ConclusionPedobarographic investigation can be useful to evaluate pressure distribution disorders in RA feet and may provide suitable guidelines for the design of various plantar supports.

Effectiveness of pulsed electromagnetic field therapy in lateral epicondylitis

We aimed to investigate the efficacy of pulsed electromagnetic field (PEMF) in lateral epicondylitis comparing the modality with sham PEMF and local steroid injection. Sixty patients with lateral epicondylitis were randomly and equally distributed into three groups as follows: Group I received PEMF, Group II sham PEMF, and Group III a corticosteroid + anesthetic agent injection. Pain levels during rest, activity, nighttime, resisted wrist dorsiflexion, and forearm supination were investigated with visual analog scale (VAS). Pain threshold on elbow was determined with algometer. All patients were evaluated before treatment at the third week and the third month. VAS values during activity and pain levels during resisted wrist dorsiflexion were significantly lower in Group III than Group I at the third week. Group I patients had lower pain during rest, activity and nighttime than Group III at third month. PEMF seems to reduce lateral epicondylitis pain better than sham PEMF. Corticosteroid and anesthetic agent injections can be used in patients for rapid return to activities.

Discriminative Value of Tender Points in Fibromyalgia Syndrome

OBJECTIVE The aim of this study is to assess the discriminative value of all tender points, alone and in combination, that are designated as criteria for fibromyalgia diagnosis by the American College of Rheumatology (ACR), by investigating the appropriate pressure magnitude that should be applied during tenderness examination. DESIGN Cross-sectional. PATIENTS This study was performed on 66 patients with fibromyalgia diagnosed according to ACR classification criteria and 50 control subjects. SETTING The outpatient rheumatology clinic of a PM&R department of a university hospital. Intervention. Pressure pain threshold values were measured by a dolorimeter on nine specific point pairs in both groups and a cutoff value for discriminating positivity and negativity was calculated for each. Then the most valuable tender point pairs were assessed for discrimination of fibromyalgia syndrome using ACR criteria set as a reference standard. RESULTS All tender points with determined pressure cutoff values were found out to significantly discriminate fibromyalgia syndrome and their area under curve values ranged from 0.779 to 0.934. Univariate logistic regression analysis revealed that lateral epicondyle and supraspinatus point pairs had the most powerful discriminative ability (odds ratio = 113.6 and 45.0, respectively). Multiple logistic regression analysis with backward stepwise method showed that lateral epicondyle and second rib point pairs were most discriminative with sensitivity and specificity rates of 87.9-94.0% and 77.3-84.0%, respectively. CONCLUSIONS Fibromyalgia syndrome can have potential to be recognized simply by pressing fewer tender point areas but with various pressure cutoff levels identified for each tender point areas.

Risk of falls in patients with ankylosing spondylitis.

BackgroundRisk of vertebral fractures is increased in patients with ankylosing spondylitis (AS). The underlying mechanisms for the elevated fracture risk might be associated with bone and fall-related risks. The aims of this study were to evaluate the risk of falls and to determine the factors that increase the risk of falls in AS patients. MethodsEighty-nine women, 217 men, a total of 306 AS patients with a mean age of 40.1 ± 11.5 years from 9 different centers in Turkey were included in the study. Patients were questioned regarding history of falls within the last 1 year. Their demographics, disease characteristics including Bath AS Disease Activity Index, Bath AS Metrology Index (BASMI), Bath AS Functional Index (BASFI), and risk factors for falls were recorded. The Short Physical Performance Battery (SPPB) test was used for evaluation of static and dynamic balance. Erythrocyte sedimentation rate, C-reactive protein, and 25-hydroxyvitamin D levels were measured. ResultsForty of 306 patients reported at least 1 fall in the recent 1 year. The patients with history of falls had higher mean age and longer disease duration than did nonfallers (P = 0.001). In addition, these patients’ BASMI and BASFI values were higher than those of nonfallers (P = 0.002; P = 0.000, respectively). We found that the patients with history of falls had lower SPPB scores (P = 0.000). We also found that the number of falls increased with longer disease duration and older age (R = 0.117 [P = 0.041] and R = 0.160 [P = 0.005]). Our results show that decreased SPPB scores were associated with increased number of falls (R = 0.183, P = 0.006). Statistically significant correlations were found between number of falls and AS-related lost job (R = 0.140, P = 0.014), fear of falling (R = 0.316, P = 0.000), hip involvement (R = 0.112, P = 0.05), BASMI (R =0.234, P = 0.000), and BASFI (R = 0.244, P = 0.000). ConclusionsAssessment of pain, stiffness, fatigue, and lower-extremity involvement as well as asking for a history of falls will highlight those at high risk for further falls. In addition to the general exercise program adopted for all patients, we suggest that a balance rehabilitation program should be valuable for the patients with risk factors for fall. Exercise may improve fear of falling and BASFI and BASMI scores. However, further study is needed to investigate these hypotheses. We believe that clinicians should train and support the patients via reducing fear of falls and maintaining good posture and functional capacity.

Probable osteosarcoma risk after prolonged teriparatide treatment: Comment on the article by Saag et al

To the Editor: Teriparatide is known to be effective in increasing levels of bone turnover biomarkers in institutionalized, mostly nonambulatory adults with severe developmental disabilities. Its use has been approved by the US Food and Drug Administration (FDA) only for adults (1). Contraindications to the use of teriparatide include the following: any hypercalcemic disorder, osteosarcoma, metastatic bone disease, Paget’s disease of bone, pregnancy, and radiation therapy to the skeleton or to soft tissue in which a skeletal port is exposed. A toxicity that appears to be unique to animals and not applicable to human subjects is osteosarcoma; osteosarcoma has developed in rats that have been given very high doses of either teriparatide or parathyroid hormone 1–84 for prolonged periods of time (2–4). It is unlikely that this animal toxicity is related to human skeletal physiology (5,6), but the FDA issued a black box warning with the approval of teriparatide. Treatment with teriparatide is approved by the FDA for a limited duration of 18–24 months, and in many European countries approval is limited to 18 months. In some recent studies, the period of treatment with teriparatide was prolonged to 24–30 months (1,7). It has been reported that a longer treatment period may have a role in the development of various pathologies in animals, one of which is osteosarcoma (3). Although this has not been observed in humans to date, longer-term use of teriparatide, especially in the young population that makes up a great proportion of patients with glucocorticoid-induced osteoporosis, may cause risks. Because the exact relationship between the occurrence of osteosarcoma and the duration of treatment has not been clearly elucidated, it is difficult to determine an exact duration of treatment after which risk might develop. The most significant problem that patients will experience is not drug tolerance, but malignancy. In the study by Saag et al published in the November 2009 issue of Arthritis & Rheumatism (8), teriparatide was used for up to 36 months in a patient population with a short duration of osteoporosis, which carries more prominent risks. We believe this prolonged treatment may have increased the risk of osteosarcoma occurrence. Although it has been reported that the teriparatide-related risk of osteosarcoma development is low (9), there are still no clear scientific data, and the general recommendation about this treatment is to closely follow up patients who have risk factors (10). Therefore, we have the following questions about the study by Saag et al: How was the treatment duration planned? Were the patients evaluated for risk of osteosarcoma development before the study? Did the authors experience difficulties with the ethical approval process? And how will the study patients be followed up prospectively in terms of osteosarcoma risk? Nurettin Tastekin, MD Trakya University Edirne, Turkey Coskun Zateri, MD On Sekiz Mart University Canakkale, Turkey

Laboratory evaluation in rheumatic diseases

Autoantibodies can help clinicians to allow early detection of autoimmune diseases and their clinical manifestations, to determine effective monitoring of prognosis and the treatment response. From this point, they have a high impact in rheumatic disease management. When used carefully they allow rapid diagnosis and appropriate treatment. However, as they may be present in healthy population they may cause confusion for interpreting the situation. False positive test results may lead to wrong treatment and unnecessary anxiety for patients. Autoantibody positivity alone does not make a diagnosis. Similarly, the absence of autoantibodies alone does not exclude diagnosis. The success of the test is closely related to sensitivity, specificity and likelihood ratios. So, interpretation of these is very important for a proper laboratory evaluation. In conclusion, in spite of the remarkable advances in science and technology, a deeply investigated anamnesis and comprehensive physical examination still continue to be the best diagnostic method. The most correct approach is that clinicians apply laboratory tests to confirm or exclude preliminary diagnosis based on anamnesis and physical examination. This review will discuss these issues.

Reliability and validity of the Turkish version of the fibromyalgia rapid screening tool (FiRST)

[Purpose] An easy-to-use, psychometrically validated screening tool for fibromyalgia is needed. This study aims to evaluate the reliability and validity of the Turkish version of the Fibromyalgia Rapid Screening Tool by correlating it with 2013 American College of Rheumatology alternative diagnostic criteria and the Hospital Anxiety and Depression Scale. [Subjects and Methods] Subjects were 269 Physical Medicine and Rehabilitation clinic outpatients. Patients completed a questionnaire including the Fibromyalgia Rapid Screening Tool (twice), 2013 American College of Rheumatology alternative diagnostic criteria, and the Hospital Anxiety and Depression Scale. Scale reliability was examined by test-retest. The 2013 American College of Rheumatology alternative diagnostic criteria was used for comparison to determine criterion validity. The sensitivity, specificity, and positive and negative likelihood ratios were calculated according to 2013 American College of Rheumatology alternative diagnostic criteria. Logistic regression analysis was conducted to find the confounding effect of the Hospital Anxiety and Depression Scale on Fibromyalgia Rapid Screening Tool to distinguish patients with fibromyalgia syndrome. [Results] The Fibromyalgia Rapid Screening Tool was similar to the 2013 American College of Rheumatology alternative diagnostic criteria in defining patients with fibromyalgia syndrome. Fibromyalgia Rapid Screening Tool score was correlated with 2013 American College of Rheumatology alternative diagnostic criteria subscores. Each point increase in Fibromyalgia Rapid Screening Tool global score meant 10 times greater odds of experiencing fibromyalgia syndrome. [Conclusion] The Turkish version of the Fibromyalgia Rapid Screening Tool is reliable for identifying patients with fibromyalgia.

The Effectiveness of Structured Group Education on Ankylosing Spondylitis Patients.

Background Ankylosing spondylitis (AS) is a common inflammatory rheumatic disease that affects the axial skeleton which can lead to structural and functional impairments. It has a negative impact on the persons daily life activities. Early diagnosis, exercise and patient education are factors playing a major role on prognosis. Objective The purpose of the study was to compare the structured theoretical and exercise educational program with routine clinic educational efforts on the parameters of the disorder over a 3 month follow up. Materials and Methods This randomized, educational intervention study was performed on 41 AS patients. A 5 day structured education and exercise program was applied to the first group of patients (Group 1) in subgroups consisting 4–5 patients each. Patients had group exercises throughout the education program. The second group followed routine clinical care. The effectiveness of the treatment was assessed by Bath ankylosing spondylitis functional (BASFI), Bath ankylosing spondylitis disease activity (BASDAI), Bath ankylosing spondylitis global (BAS-G), Bath ankylosing spondylitis metrology indices (BASMI), chest expansion, short form-36 (SF-36), ankylosing spondylitis quality of life scale (ASQoL) and laboratory parameters in all patients. Patients were evaluated on initiation and after 3 months. Results Significant improvements in BASFI, BASDAI and BAS-G, chest expansion, SF-36 and ASQoL indices were observed in Group 1 No difference could be found in BASMI and chest expansion. Conclusion A structured educational and exercise intervention had a positive effect on the functional status,disease activity, and general well-being and quality of life. It also, shows that education programs should be within the routine treatment program for AS.

AB0927 Reliability and validity of turkish version of fibromyalgia participation questionnaire

Background Fibromyalgia (FMS) is a chronic health problem characterized by a wide range of physical and psychological symptoms. There are few high-quality instruments to evaluate the participation and social functioning of fibromyalgia patients. Farin et al. designed the Fibromyalgia Participation Questionnaire (FPQ) as an instrument for measuring the participation and social functioning of FMS patients. The original version of FPQ has been demonstrated to have acceptable internal consistency, reliability and criterion validity. Objectives To test reliability and validity of Turkish version of Fibromyalgia Participation Questionnaire (FPQ-T) Methods One hundred and eighty-four female fibromyalgia syndrome patients were included in the study. All patients filled FPQ-Turkish (FPQ-T) questionnaire which was obtained by translation from German according to the guideline for the cross-cultural adaptation process. The patients filled the revised Fibromyalgia Impact Questionnaire (FIQ) and reevaluated FPQ-T two hours later. Internal consistency reliability of FPQ-T was assessed by calculating “if item deleted” using Cronbach alpha and “item-total correction” coefficient for each item of the questionnaire. Consistency of sub-scales and correlation of test-retest values were assessed. Test-retest values were compared using Wilcoxon test. Criterion validity was measured using FIQ scales by Spearmans rho correlation coefficient. Results For internal reliability, Cronbach alpha coefficient was calculated as 0.957 for non-working and 0.958 for working patients. Cronbach alpha values of 0.939, 0.871, and 0.914 were obtained for daily, social, and work life, respectively. Correlation coefficients were 0.888 for daily life, 0.859 for social life, and overall 0.901 in non-working group versus 0.896 in working group. Comparison of scores obtained from test-retest measurements showed no significant difference except for Item-3. Correlation of symptom severity score (SSS) and FPQ-T were r=0.385 (p<0.001) and r=0.390 (p<0.001) for the non-working and working sub-groups, respectively. Construct validity evaluation showed significant correlation between SSS and FPQ-T. Conclusions The results of our study showed that FPQ-T is reliable and valid for assessing participation and social functioning in fibromyalgia patients in our society. References Williams DA, Clauw DJ (2009) Understanding fibromyalgia: Lessons from the broader pain research community. J Pain 10:777–791. Farin E, Ullrich A, Hauer J (2013) Participation and social functioning in patients with fibromyalgia: development and testing of a new questionnaire. Health Qual Life Outcomes 11:135. Disclosure of Interest None declared