Acute back pain: The role of medication, physical medicine and rehabilitation: WFNS spine committee recommendations.

Objectives: To formulate the most current, evidence-based recommendations for the role of medication, physical medicine, and rehabilitation in the management of acute low back pain lasting <4 weeks. Methods: A systematic literature search in PubMed and Google Scholar databases was performed from 2012 to 2022 using the search terms "acute low back pain," "drugs," "bed rest," "physical medicine," rehabilitation." Standardized screening criteria resulted in a total of 39 articles that were analyzed, including 16 RCTs, 8 prospective studies, 6 retrospective studies, and 9 systematic reviews. This up-to-date information was reviewed and presented at two separate meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Two rounds of the Delphi method were utilized to vote on the statements and arrive at a positive or negative consensus. Results and conclusion: The WFNS Spine Committee finalized twelve recommendation guidelines on the role of medication, physical medicine and rehabilitation in the management of acute LBP. We advocate for a uniform approach to the treatment of these patients, including proper patient education and utilizing drugs with proven efficacy and minimal side effects. First-line pharmacologic agents are acetaminophen and NSAIDs; muscle relaxants can be used for spasms and pain reduction, and opioids should be minimized. Continued activity, rather than bed rest, is recommended, and lumbar spine orthotics may be used to reduce pain and augment functional status. Thermotherapy, cryotherapy, TENs, spinal manipulative therapy, and acupuncture may all be used as adjuncts to improve acute LBP.

Efficacy of platelet-rich plasma in the treatment of hemiplegic shoulder pain.

OBJECTIVE: The aim of this study was to examine the effects of platelet-rich plasma (PRP) on pain and functional outcomes in patients with hemiplegic shoulder pain. We compared the effects of PRP against saline solution by designing a double blind, randomized, prospective study. DESIGN: Forty-four patients with hemiplegia were included in this study. All patients received a total of 3 injections, 1 week apart. The first group received PRP injections while the second group received placebo injections. After 3 months of follow-up, 40 patients completed the trial. Primary outcome measure was movement-induced pain score (VAS), and secondary outcome measures were spontaneous pain score, shoulder passive range of motion (ROM), functional independence measure score, and the amount of paracetamol used. All subjects were evaluated at baseline, 1 week, 1 month, and 3 months after the completion of the last injection. RESULTS: Both groups showed an improvement in spontaneous and movement-related pain scores and shoulder passive ROM values on 1st and 3rd month visits (p < 0.05). No significance difference was detected between groups (p > 0.05). Similarly, FIM scores improved significantly in both groups (p < 0.05) but no difference was found between groups. Paracetamol use did not differ significantly between groups. CONCLUSION: The PRP injections were found not to be superior to placebo. Improvements in both groups can be attributed to the use of rehabilitation techniques and exercises in all patients. There is still need for further research to show whether PRP is a treatment option in the course of hemiplegic shoulder pain. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03931824.

Efficacy of platelet-rich plasma injections in patients with adhesive capsulitis of the shoulder.

PURPOSE: The goal of this study is to investigate whether platelet-rich plasma (PRP) injections are effective in the management of adhesive capsulitis of the shoulder (AC). A triple-blind, randomized controlled trial was designed and conducted in a medical school hospital. METHODS: 32 adult patients with adhesive capsulitis (21 female, 11 male with a mean age of 57, ranging from 23 to 70) were included in this study. Patients had to have shoulder pain and restrictions in movements (at least 25% when compared to the other side, and at least in two directions) for three months minimum and nine months maximum. Patients were randomized to two groups, and one group took PRP injections for three times every two weeks, while the other group took saline injections in same frequency and volume. A standardized exercise program was also applied to all patients. Patients were evaluated with Shoulder Pain and Disability Index (SPADI), Visual Analogue Scales for pain and disability, ranges of movements, and use of analgesics in before, after, and third month after the initiation of the therapy. RESULTS: Baseline comparisons between groups showed no differences. SPADI and ranges of motion in all directions showed significant improvements with therapy, and the group which took PRP injections showed better improvements when compared to the control group (p < 0.05). Visual Analogue Scale was found to be better for the PRP group after therapy and third month, and not for the control group (0.4 ± 1.06 and 0.17 ± 0.72 vs. 2.5 ± 2.6 and 2 ± 2.2, respectively, p < 0.05). Use of analgesics was not found to be significant for both groups (p > 0.05). CONCLUSION: PRP injections were found to be effective in both pain and disability, and showed improvements in a restricted shoulder due to adhesive capsulitis. These findings might point out PRP as a therapeutic option in the management of adhesive capsulitis.

Occupational therapy assessment and treatment approach in patients with subacute and chronic stroke: A single-blind, prospective, randomized clinical trial.

OBJECTIVES: The aim of this study was to examine the effects of occupational therapy (OT) combined with standard rehabilitation (SR) on the activities of daily living, quality of life, and psychological symptoms of hemiplegic patients. PATIENTS AND METHODS: Between August 2014 and February 2016, a total of 35 hemiplegic patients with post-diagnostic periods (19 males, 16 females; mean age 58.3 years; range 37 to 77 years) were included. The patients were randomized into two groups as OT+SR group (n=17) and SR only group (n=18). The study was completed by 16 patients in each group. The patients in the OT group were given 45-min SR five days a week plus 45-min OT three days a week over an eight-week period, while the patients in the SR group received SR only (of the same duration and frequency as the OT group). The patients were assessed at enrolment (pre-treatment), and again after eight weeks of treatment using the Pinch and Grip Strength and the Purdue Pegboard tests, Global Daily Living Activities Scale, Performance Assessment of Self-care Skills (PASS), Nottingham Extended Activities of Daily Living (NEADL) Scale, Quality of Life Short Form (SF-36) Questionnaire, and Hospital Anxiety and Depression Scale (HAD) for their psychological state. RESULTS: Significant improvements were observed in within-group scores for PASS, Pinch and Grip Strength Test, NEADL Scale, and Purdue Pegboard test (p<0.05). After treatment, a significant increase was found in the SF-36 physical function, general health and physical total in-group scores of the OT group, whereas a significant increase was observed only in the physical total scores of the SR group (p<0.05). There was no significant improvement in the HAD scores within both groups (p>0.05). Inter-group comparisons revealed a further significant improvement in PASS instrumental daily activity index-physical subscale and Purdue Pegboard Test scores of the OT group (p<0.05). However, there was no significant difference in PASS activity, self-care and instrumental daily activity cognitive subscale, SF-36, HAD and hand grip and pinch strength scores between the groups (p>0.05). CONCLUSION: Occupational therapy combined with SR applications has a beneficial impact on certain daily living activities and hand functions. Occupational therapy does not have any additional benefits on the quality of life, pinch and grip strength, and the psychological state.

Updated approach for the management of osteoporosis in Turkey: a consensus report.

As a result of the current demographics, increased projections of osteoporosis (OP) and prevalence of the disease in Turkey, a panel of multidisciplinary experts developed a thorough review to assist clinicians in identifying OP and associated fracture risk patients, diagnosing the disease with the appropriate available diagnostic methods, classifying the disease, and initiating appropriate treatment. The panel expects to increase the awareness of this prevalent disease, decrease consequences of OP with corresponding cost savings and, ultimately, decrease the overall burden of OP and related fractures in Turkey. BACKGROUND: OP is not officially accepted as a chronic disease in Turkey despite the high prevalence and predicted increase in the following years. However, there are areas where the country is performing well, such as having a country-specific fracture risk assessment model, DXA access, and the uptake of FRAX. Additional efforts are required to decrease the existing treatment gap estimating 75-90% of patients do not receive pharmacological intervention for secondary prevention, and the diagnosis rate is around 25%. METHODS: A selected panel of Turkish experts in fields related to osteoporosis was provided with a series of relevant questions to address prior to the multi-day conference. Within this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion until a consensus was achieved. Represented in the panel were a number of societies including The Turkish Osteoporosis Society, The Society of Endocrinology and Metabolism of Turkey (SEMT), and The Turkish Society of Physical Medicine and Rehabilitation. RESULTS: Standardized general guidelines to identify OP and related fractures and at-risk population in Turkey, which will enable clinicians to accurately and effectively diagnose the disease, treat the appropriate patients with available pharmacological and non-pharmacological treatments and decrease the burden of the disease. CONCLUSIONS: This manuscript provides a review of the current state of OP and related fractures in Turkey. Moreover, this manuscript reviews current international guidelines and national studies and proposes a number of helpful country-specific classifications that can be used by healthcare providers caring for the at-risk population. Additionally, the panel proposes practical recommendations that should be implemented nationally in order to decrease the burden of OP and related fractures and effectively preventing the burden in future generations.

The burden of osteoporosis in Turkey: a scorecard and economic model.

The burden of osteoporosis in Turkey is not well characterized. Our results indicate that osteoporosis is undertreated in Turkey with 1.35 million fractures predicted to occur from 2019 to 2023 at an associated cost of 2.42 billion USD. Interventions are needed to close the treatment gap and minimize the economic burden. PURPOSE: The number of osteoporotic fractures is expected to increase as populations age, posing a major risk to health systems and patients. We created a scorecard summarizing the burden of disease, policy framework, service provision, and service uptake for osteoporosis in Turkey and estimated the economic burden of osteoporotic fractures in Turkey. METHODS: A systematic review of osteoporosis in Turkey was performed. Gaps in the literature were supplemented by surveys with osteoporosis experts. The findings were used to populate a scorecard and burden of illness model focused on adults aged 50 to 89 years in Turkey. The scorecard provided a visual representation of osteoporosis burden and management using a traffic light color coding system. The model quantified osteoporosis-related fracture costs (2019 USD) including hospitalizations, dual-energy x-ray absorptiometry testing, hip fracture surgery, prescription drugs, and patient productivity losses. RESULTS: The scorecard showed that osteoporosis is undertreated in Turkey. Despite timely access to diagnosis, > 75% of high-risk patients fail to initiate on appropriate therapies. In 2019, the economic model predicted that 255,183 osteoporosis-related fractures would occur in Turkey with an associated annual cost of approximately 455 million USD and an average burden per 1000 at risk of 23,987 USD. The cumulative 5-year cost of 1,354,817 fractures was 2.42 billion USD. CONCLUSIONS: Approximately 1.35 million fragility fractures are predicted to occur in Turkey during the next 5 years with costs of 2.42 billion USD. Closing the treatment gap will be imperative for preventing these fractures and minimizing the burden of osteoporosis in Turkey.

The effects of upper extremity aerobic exercise in patients with spinal cord injury: a randomized controlled study.

BACKGROUND: Immobility and secondary complications, including cardiopulmonary disease, pressure ulcers, and pain, occur in patients with spinal cord injury (SCI). These patients also have difficulty coping with the strain of daily activities. Thus, it is important for SCI patients to engage in aerobic exercise in order to be able to cope adequately with the strain of activities and SCI-related complications. AIM: The aim of this study was to investigate the effects of arm aerobic exercise on the parameters of cardiopulmonary function, quality of life, degree of disability, psychological state, and metabolic syndrome. DESIGN: This study was a single blind, randomized, controlled trial. SETTING: This study was conducted in a university hospital. POPULATION: SCI patients were randomly assigned to an intervention group (N.=17) or a control group (N.=16). Arm ergometer exercises (three days/week; 1.5 hours/week 50-70% pVO2) and general exercises (two sessions/day; 5 days/week), were assigned to the intervention group for 12 weeks. The control group was assigned general exercises only during this trial. METHODS: Before the rehabilitation (Week 0), after six weeks, and after the rehabilitation (Week 12), all patients were evaluated for functional status (maximal oxygen uptake [pVO2], power output [PO], and Functional Independence Measurement), pulmonary function (FEV1%, FVC%, FEV1/FVC%), quality of life (World Health Organization Measure of Quality of Life, short form, Turkish version), metabolic syndrome parameters (triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fasting blood sugar, waist circumference, and systolic and diastolic blood pressure), degree of disability (Craig Handicap Assessment and Reporting Technique, short form), and psychological status (Center for Epidemiologic Studies Depression Scale and Hospital Anxiety and Depression Scale). RESULTS: At the end of the study, increases of 39.6% and 45.4% in the pVO2 and PO levels, respectively, were found. Additionally, no statistically significant difference was found in the intervention group after the rehabilitation compared to the levels before rehabilitation (P<0.05). However, no statistically significant differences in functional status, quality of life, psychological state, level of disability, or metabolic syndrome parameters were found in the intervention group (P>0.05). The control group, on the other hand, showed no clinically significant differences in any of the parameters (P>0.05). CONCLUSIONS: Short-term arm aerobic exercise performed by patients with SCI improves their exercise capacities. These patients require longer rehabilitation programs to receive more benefits from aerobic exercise training. CLINICAL REHABILITATION IMPACT: Adding arm cranking exercise training to the rehabilitation program of patients with spinal cord injury demonstrated improved exercise capacity; however, further studies are needed to assess the effects of exercise training on other health issues.

Predictive validity of the ASAS classification criteria for axial and peripheral spondyloarthritis after follow-up in the ASAS cohort: a final analysis.

OBJECTIVE: To establish the predictive validity of the Assessment of SpondyloArthritis international Society (ASAS) spondyloarthritis (SpA) classification criteria. METHODS: 22 centres (N=909 patients) from the initial 29 ASAS centres (N=975) participated in the ASAS-cohort follow-up study. Patients had either chronic (>3 months) back pain of unknown origin and age of onset below 45 years (N=658) or peripheral arthritis and/or enthesitis and/or dactylitis (N=251). At follow-up, information was obtained at a clinic visit or by telephone. The positive predictive value (PPV) of the baseline classification by the ASAS criteria was calculated using rheumatologist's diagnosis at follow-up as external standard. RESULTS: In total, 564 patients were assessed at follow-up (345 visits; 219 telephone) with a mean follow-up of 4.4 years (range: 1.9; 6.8) and 70.2% received a SpA diagnosis by the rheumatologist. 335 patients fulfilled the axial SpA (axSpA) or peripheral SpA (pSpA) criteria at baseline and of these, 309 were diagnosed SpA after follow-up (PPV SpA criteria: 92.2%). The PPV of the axSpA and pSpA criteria was 93.3% and 89.5%, respectively. The PPV for the 'clinical arm only' was 88.0% and for the 'clinical arm'±'imaging arm' 96.0%, for the 'imaging arm only' 86.2% and for the 'imaging arm'+/-'clinical arm' 94.7%. A series of sensitivity analyses yielded similar results (range: 85.1-98.2%). CONCLUSIONS: The PPV of the axSpA and pSpA criteria to forecast an expert's diagnosis of 'SpA' after more than 4 years is excellent. The 'imaging arm' and 'clinical arm' of the axSpA criteria have similar predictive validity and are truly complementary.

Longitudinal study of bone loss in chronic spinal cord injury patients.

[Purpose] This prospective longitudinal study evaluated the changes in bone metabolism markers and bone mineral density of spinal cord injury patients over 3 years. We also assessed the relationships among the bone mineral density, bone metabolism, and clinical data of spinal cord injury patients. [Subjects and Methods] We assessed the clinical data (i.e., immobilization due to surgery, neurological status, neurological level, and extent of lesion) in 20 spinal cord injury patients. Bone mineral density, and hormonal and biochemical markers of the patients were measured at 0, 6, 12, and 36 months. [Results] Femoral neck T score decreased significantly at 36 months (p < 0.05). Among the hormonal markers, parathyroid hormone and vitamin D were significantly elevated, while bone turnover markers (i.e., deoxypyridinoline and osteocalcin) were significantly decreased at 12 and 36 months (p < 0.05). [Conclusion] Bone mineral density of the femoral neck decreases significantly during the long-term follow-up of patients with spinal cord injury due to osteoporosis. This could be due to changes in hormonal and bone turnover markers.

Intrafusal effects of botulinum toxin injections for spasticity: revisiting a previous paper.

Botulinum toxin, frequently used to manage focal limb spasticity, has been reported to affect both extrafusal and intrafusal fibers of the injected muscle. Since most studies have used spinal reflexes, it is difficult to isolate the intrafusal effects from extrafusal and central effects. In a paper by On et al. [7], both stretch and H-reflexes were used to examine the intrafusal effects of botulinum toxin injections. Revisiting the data from On et al. [7] presented a unique opportunity to describe a novel method of measuring the effect of botulinum toxin-A on muscle spindle activity in patients with spasticity. H-reflex, maximum M-wave, and Achilles tendon reflex were serially assessed in ten patients with stroke pre-, 2, 4, and 12 weeks post-botulinum. In order to assess the intrafusal effects, we subtracted the %change in H-reflex amplitude from baseline (representing extrafusal and central effects) from the %change in Achilles tendon reflex amplitude from baseline (representing intrafusal, extrafusal and central effects). Using this formula, our results suggest that botulinum induces significant chemodenervation of the intrafusal muscle fibers (33% decreases). Intrafusal effects were greatest at 2 weeks, but tapered off by 12 weeks post-botulinum (p<0.017). We found a significant positive correlation between the intrafusal effects of botulinum toxin and changes in modified Ashworth scale. Our method of assessing the effects of botulinum toxin shows significant effect on intrafusal fibers, which correlates with clinical manifestation of spasticity. Future studies need to investigate ways to maximize intrafusal effects and minimize extrafusal effects of botulinum therapy.

Interferential current therapy in patients with knee osteoarthritis: comparison of the effectiveness of different amplitude-modulated frequencies.

OBJECTIVE: This study aimed to compare the effectiveness of different amplitude-modulated frequencies of interferential current (IFC) and sham IFC on knee osteoarthritis. DESIGN: A randomized and single-blind study was performed on 60 patients diagnosed with knee osteoarthritis. The patients were allocated to three active IFC groups (40, 100, and 180 Hz), and one sham IFC group. Treatments were performed 5 times a week for 3 wks consecutively. Each patient was assessed at the end of the treatments and at the first month using the following measurements: visual analog scale (pain at rest, pain on movement and disability), physician and patient judgments regarding treatment effectiveness, 15-m walking time (in minutes), range of motion (ROM), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and paracetamol intake (g/wk). RESULTS: Although there were significant improvements in all variables, except WOMAC stiffness and range of motion, measured in all groups at the end of the treatment and during the follow-up, this improvement was greater in active IFC groups than in the sham group. The improvement in WOMAC stiffness was observed only in active IFC treatment groups (P < 0.05). No significant difference between different amplitude-modulated frequencies of IFC treatments was observed. CONCLUSIONS: This study demonstrated the superiority of the IFC with some advantages on pain and disability outcomes when compared with sham IFC for the management of knee osteoarthritis. However, the effectiveness of different amplitude-modulated frequencies of IFC was not superior when compared with each other.

Does betahistine treatment have additional benefits to vestibular rehabilitation?

The aim of this study was to investigate the effect of high-dose betahistine treatment added to vestibular rehabilitation (VR) on the disability, balance and postural stability in patients with unilateral vestibular disorder. The VR group (group 1, n = 24) and the VR + betahistine group (group 2, n = 23) were analyzed retrospectively. All patients were evaluated before and after an 8-week customized VR in terms of disability (Dizziness Handicap Inventory, DHI), dynamic balance [Dynamic Gait Index (DGI)] and postural stability (static posturography). In group 1 and group 2, differences between DHI, DGI and falling index score on static posturography before and after the exercise program were significant (p < 0.05). In addition, a significant difference was detected only in group 2 in the variables evaluated in static posturography-Fourier 4 analysis (p < 0.05). Both VR and betahistine + VR have a positive effect on disability and balance in patients with unilateral vestibular disorder. Betahistine treatment added to VR was effective in increasing postural stability.

Reliability, validity, and sensitivity to change of Turkish Activities-specific Balance Confidence Scale in patients with unilateral peripheral vestibular disease.

The aim of this study is to evaluate the internal consistency, test-retest reliability, construct validity, and sensitivity to change of the Activities-specific Balance Confidence Scale (ABC) in people with peripheral vestibular disorder. Thirty-three patients with unilateral peripheral vestibular disease were included in the study. Patients were also evaluated with the Visual Analog Scale, the Romberg test (eyes open, closed), the tandem Romberg test (eyes open, closed), standing on foam (eyes open, closed), static posturography, Five Times Sit to Stand test, Timed Up to Go test, gait speed, Dynamic Gait Index, Functional Gait Assessment, and Dizziness Handicap Inventory. To assess sensitivity to change, 27 patients were involved in a 4-week customized vestibular rehabilitation program and then reassessed at the end of 4 weeks. The individual item intraclass correlation coefficient ranged from 0.67 to 0.92 and Crohnbach alpha ranged from 0.67 to 0.93. The Crohnbach a value for whole scale was determined as 0.95. Although the Dizziness Handicap Inventory showed significant correlation with the Turkish ABC Scale (r= 0.51 - 0.54, P < 0.05), no such a correlation was observed between the Turkish ABC Scale and the other parameters assessed (P >0.05). Both Turkish ABC Scale and the other parameters assessed showed significant improvement after 4-week customized exercise program (P< 0.05). The Turkish ABC Scale is a culturally relevant, reliable, and sensitive to change tool for measuring self-perceived balance confidence in unilateral peripheral vestibular disease.

Short-term effects of vestibular rehabilitation in patients with chronic unilateral vestibular dysfunction: a randomized controlled study.

OBJECTIVE: To evaluate the short-term effects of vestibular rehabilitation on symptom, disability, balance, and postural stability in patients with chronic unilateral vestibular dysfunction. DESIGN: Randomized controlled trial. SETTING: Department of Physical Medicine and Rehabilitation, University Hospital. PARTICIPANTS: Patients (N=42) with chronic vestibular dysfunction were divided into either a rehabilitation group (group 1) or a control group (group 2). INTERVENTIONS: Patients in group 1 were treated with a customized exercise program for 4 weeks, while the patients in the control group did not receive any treatment. MAIN OUTCOME MEASURES: Subjects were assessed before and after the rehabilitation program with respect to symptoms (visual analog scale [VAS]), disability (Dizziness Handicap Inventory [DHI]), balance (Berg Balance Scale [BBS]), and postural stability (modified Clinical Test for Sensory Interaction on Balance [mCTSIB]). RESULTS: Significant improvements in all parameters (VAS, DHI, BBS, mCTSIB) were observed in group 1 (P<.05). When the 2 groups were compared, there were significant improvements in postexercise VAS, DHI (emotional, functional, physical, total), BBS, and mCTSIB (standing on a firm surface with eyes open, standing on a foam surface with eyes open, standing on a foam surface with eyes closed, mCTSIB mean) in favor of group 1 (P<.05). No significant improvements were seen in any parameters in the control group (P>.05). CONCLUSIONS: Significant improvements were seen in symptom, disability, balance, and postural stability in chronic unilateral vestibular dysfunction after an exercise program. Customized exercise programs are beneficial in treatment of chronic unilateral vestibular dysfunction.

European consensus table on the use of botulinum toxin type A in adult spasticity.

A group of clinicians from across Europe experienced in the use of botulinum toxin type A for the treatment of spasticity following acquired brain injury gathered to develop a consensus statement on best practice in managing adults with spasticity. This consensus table summarizes the current published data, which was collated following extensive literature searches, their assessment for level of evidence and discussion among the whole group. Published information is supplemented by expert opinion based on clinical experience from 16 European countries, involving 28 clinicians, who treat an average of approximately 200 patients annually, representing many thousand spasticity treatments with botulinum toxin per year.

Comparison of isokinetic exercise versus standard exercise training in patients with chronic low back pain: a randomized controlled study.

OBJECTIVE: To compare the effectiveness of an isokinetic exercise programme and a standard exercise programme in patients with chronic low back pain in terms of pain, mobility, disability, psychological status and muscle strength. DESIGN: A randomized controlled trial. SETTING: An outpatient rehabilitation clinic. SUBJECTS: A total of 40 patients with low back pain were included in the study. INTERVENTIONS: Patients with low back pain were randomly allocated into group 1 (n=20, isokinetic exercises) and group 2 (n=20, standard exercise). MAIN MEASURES: Outcome measures included a visual analogue scale (VAS) for pain, fingertip-to-floor test for spinal mobility, Modified Oswestry Low Back Disability Questionnaire (MOLBDQ), Beck Depression Inventory and isokinetic muscle testing. RESULTS: The isokinetic and standard exercise groups demonstrated significant improvement in the VAS, fingertip-to-floor test, MOLBDQ, Beck Depression Inventory scores, and muscle strength compared with the baseline that persisted until the end of the first month (P<0.05). Comparison of both exercise groups in terms of these parameters obtained at the end of the treatment and at the first month after treatment showed no significant difference (P>0.05). CONCLUSION: Isokinetic and standard exercise programmes have an equal effect in the treatment of low back pain, with no statistically significant difference found between the two programmes. The standard exercise programme was easily performed and had a low cost, making it the preferred option for exercise.

SAPHO syndrome with adrenal deficiency: a case report.

INTRODUCTION: The SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteomyelitis) is a rare painful disorder, usually with a good long-term prognosis. Its etiology remains unclear, and various treatment regimens frequently fail to control the disease. CASE PRESENTATION: A 46-year-old Caucasian female was referred for anterior chest wall and back pain. Physical examination was unremarkable except for skin lesions noted on soles of both feet, extremities and the face. A thoracic magnetic resonance imaging study demonstrated a lesion characterized with bone marrow edema and proliferation of soft tissue in the sternum. A brain MRI was requested secondary to the elevated prolactin level which was compatible with empty sella syndrome. CONCLUSION: The case presented here has the unique feature of adrenal deficiency presenting alongside the SAPHO syndrome and is presented as the first case reported. This syndrome could become complicated with different organ system involvement other than bone and skin. There is a need further studies that will explore the weak relationship between SAPHO syndrome and adrenal deficiency.

[Fibromyalgia syndrome from the perspective of neuropathic pain]. / Nöropatik agri açisindan fibromyalji sendromu.

Fibromyalgia syndrome (FMS) is one of the several chronic pain syndromes and have been proposed to reflect some primary abnormality of the nervous system. Patients with FMS display common clinical features with neuropathic pain. The responsible mechanisms for symptoms and signs are still unknown. Mounting evidence was shown for central pain processing abnormalities in almost all FMS patients. These anomalies including hyperalgesia, allodynia, abnormal activation of pain-related brain regions and abnormal temporal summation of second pain in FMS patients strongly indicate a neuropathic pain syndrome. This new information led to the proposal that FMS may be a neuropathic pain syndrome maintained by central nervous system sensitization and sympathetic hyperactivity. This different perspective on FMS opens new avenues for research and treatment. In this review, a synthesis of the information about how FMS is related to neuropathic pain syndromes is provided.