Rehabilitation of the face and temporomandibular joint in systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) alterations of the face and of the mouth cause aesthetic modifications and disability, impairing self-esteem and quality of life (QoL). The aim of this study was to verify the effects of two rehabilitation protocols on facial mimic and mouth opening. METHODS: A total of 47 SSc patients (40 females and 7 males, mean age ± SD 59.08 ± 10.31 years), were consecutively selected: 22 were randomly assigned to protocol 1 [home exercises for temporomandibular joint (TMJ), mimic, masticatory and cervical spine muscles] and 25 to protocol 2 (home exercises and combined physiotherapeutic procedures performed by a physiotherapist). Each treatment had a duration of 12 weeks with a follow up of 8 weeks. TMJ dysfunction, orofacial involvement, disability, QoL, and safety were assessed at enrollment (T0), at the end of the treatment (T1), and at follow up (T2). RESULTS: Both Protocol 1 and Protocol 2 induced significant improvements of some clinical and clinimetric parameters, but better results were obtained with Protocol 2. In the comparison between the effects of Protocol 1 and Protocol 2 at T1 and T2, a significant difference was observed only for Mouth Handicap in SSc [MHISS; Total (p = 0.00178] and for MHISS Mouth opening (p = 0.0098) at T1. No significant difference of indices of short-form 36 was observed. CONCLUSION: The present data suggest that TMJ involvement in SSc may be managed by rehabilitation treatments. The action of a physiotherapist prescribing and personalizing exercises may induce better therapeutic effects.

Efficacy of rehabilitation with Tai Ji Quan in an Italian cohort of patients with Fibromyalgia Syndrome.

BACKGROUND: Fibromyalgia Syndrome (FMS) is characterized by musculoskeletal pain, muscle tenderness leading to disability, impaired quality of life (QoL), fatigue and it is accompanied by sleep disorders and psychological distress. Mind body therapies (MBT), such as Tai Ji Quan (TJQ), use different techniques to facilitate the ability of the mind to influence disease characteristics and symptoms. Some studies showed that TJQ, in patients with rheumatic diseases, particularly FMS, improved QoL, disability and psychological distress. OBJECTIVES: To evaluate the efficacy of TJQ on disability, QoL, fatigue, sleep and psychological distress in an Italian cohort of FMS patients. METHODS: We enrolled 44 FMS patients: 22 patients (Experimental Group) participated to a course of Tai Ji Quan style of (2/week for 16 weeks); 22 patients (Control Group) participated to an educational course about FMS (2/week for 16 weeks). At baseline (T0) and at the end of treatment (T1), patients were assessed for disability [Fibromyalgia Impact Questionnaire (FIQ), Health Assessment Questionnaire (HAQ)], Quality of Life [Short-Form 36 (SF36)], fatigue [Functional Assessment of Chronic Illness-Fatigue (FACIT-F)], pain [Widespread Pain Index (WPI)], tenderness [Tender Points (TP)], Sleep Quality [Pittsburgh Sleep Quality Index (PSQI)] and mood disorders [Hospital Anxiety and Depression Scale (HADS)]. RESULTS: At T1 versus T0, patients of the Experimental Group showed a significant improvement in FIQ, FACIT, SF36 (Summary Physical Index, Physical activity, physical role, bodily pain, general health, vitality, emotional role limitations), in WPI, TP, PSQI (total, sleep duration, and sleep disturbance) and HADS (total score and anxiety subscale), while Patients in the Control Group did not improve in any parameter. CONCLUSIONS: In FMS patients TJQ, if performed by an expert physiotherapist, should be regarded as an effective rehabilitation method.

Women With Primary Sjögren Syndrome and With Non-Sjögren Sicca Syndrome Show Similar Vulvar Histopathologic and Immunohistochemical Changes.

The goal of this study was to evaluate the characteristics and the prevalence of histopathologic and immunohistochemical changes in vulvar biopsies, in women with Primary Sjögren Syndrome (pSS) and non-Sjögren Sicca Syndrome (nS-SS). Twenty-one women with pSS and 11 with nS-SS (investigated by xerophtalmia and xerostomia tests, biopsy of minor salivary glands, gynecological history, and gynecologic symptoms score) underwent vulvar biopsies, evaluated for histopathologic and immunohistochemicalchanges, and compared with those obtained from 26 patients with lichen sclerosus. An inflammatory infiltrate was present in 31/32 biopsies (96.9%); biopsies from pSS patients showed a mild infiltrate in 10 cases and a moderate infiltrate in 11 cases; and patients with nS-SS had a mild infiltrate in 8 biopsies and moderate infiltrate in the other 2 biopsies. By immunohistochemistry, the infiltrate was composed predominantly of T lymphocytes (CD3), CD20 B cells were sparse and mean CD4:CD8 T-cell ratio was 1.5. No differences were observed between the grading of the inflammatory infiltrate in nS-SS and pSS; no correlation was shown between vulvar inflammatory infiltrate score (mild or moderate) and salivary glands inflammatory score. No differences were found in gynecologic symptoms, as well as in clinical and demographical characteristics between patients with mild and those with moderate vulvar inflammatory score. A higher prevalence of moderate inflammatory infiltrate was observed in biopsies from women with lichen sclerosus than in pSS and nS-SS patients (61.5% vs. 27.5%, P=0.02). Women with pSS and nS-SS show a high and similar prevalence of vulvar inflammatory infiltrate. A gynecologic evaluation is needed both in pSS and nS-SS to assess genital involvement and, eventually, to address a therapy targeted to genital symptoms.

Systemic sclerosis: rehabilitation as a tool to cope with disability.

In patients with systemic sclerosis (SSc), local disability of the hands and face, due to the involvement of skin, subcutaneous tissues and musculoskeletal system, is scarcely improved by pharmacological therapy, but may be treated efficaciously with rehabilitation, which can prevent and reduce local disability, thus ameliorating global disability and impaired Quality of Life, related to changes in the hands and face. In SSc, in order to be efficacious, rehabilitation should: 1. include and use both local treatments of hands and face and global rehabilitation techniques; 2. be different according to the different SSc phases and subsets; 3. include different techniques to tailor treatment to the personal needs and abilities of the patients.

Mind body therapies in rehabilitation of patients with rheumatic diseases.

Mind body therapies (MBT) share a global approach involving both mental and physical dimensions, and focus on relationship between brain, mind, body and behavior and their effects on health and disease. MBT include concentration based therapies and movement based therapies, comprising traditional Oriental practices and somatic techniques. The greatest part of rheumatic diseases have a chronic course, leading to progressive damages at musculoskeletal system and causing physical problems, psychological and social concerns. Thus, rheumatic patients need to be treated with a multidisciplinary approach integrating pharmacological therapies and rehabilitation techniques, that not should only aim to reduce the progression of damages at musculoskeletal system. Thus, MBT, using an overall approach, could be useful in taking care of the overall health of the patients with chronic rheumatic diseases. This review will deal with different MBT and with their effects in the most common chronic rheumatic diseases (Rheumatoid Arthritis, Ankylosing Spondylitis, Fibromyalgia Syndrome).

Biomechanical podiatric evaluation in an Italian cohort of patients with systemic sclerosis: A pilot study.

OBJECTIVE: Foot problems are often present in Systemic Sclerosis (SSc) patients, however studies regarding podiatric problems related to SSc are lacking and there are no data evaluating the foot biomechanical changes. The aim of the present pilot study was to evaluate podiatric problems in an Italian cohort of SSc patients by assessing received podiatric services, foot pain and disability and biomechanical foot deformity. MATERIAL AND METHODS: 25 consecutive SSc patients were enrolled from the Division of Rheumatology, University of Florence. All SSc patients were assessed by: Standards of Care for People with Foot Musculoskeletal Health problems: Audit Tool, Foot Function Index (FFI), Weight and non-weight bearing foot joint assessment, (Foot Posture Index (FPI) and Gait Cycle), Health Assessment Questionnaire (HAQ) and Medical Outcomes Survey Short Form 36 (SF-36). RESULTS: Audit Tool - Only 7 (28%) out of the 25 patients with SSc had a specific podiatric assessment and treatment: no patient received a foot health assessment within the first 6 months of disease diagnosis and no patient received information about foot involvement. 1 patient (4%) received foot assessment every year; 1 patient (4%) received specific information about the disease and 5 patients (20%) received information about the benefits of using adapted footwear and insoles. FFI - Values of pain, disability and activity limitations, reported in FFI, are 4.7±5.1, 5.1±3.2 and 3.2±3.1 (M±DS), respectively. Non-weight bearing foot joint assessment shows a rearfoot varus deformity in 64% of patients, forefoot varus deformity in 42% and 6% forefoot valgus deformity. Weight bearing foot joint assessment, through FPI shows a pronated foot 20% of patients with and 34% with highly pronated overall foot posture. Gait analysis shows that 64% of patients has a contact of the calcaneus in invertion while 36% in eversion. In the midstance, 78% have the foot in pronation and 22% in supination, while in propulsion 12% presents a takeoff of the foot in supination and 88% in the pronation. HAQ result is 1.13±0.80, SFI and SMI scales of SF-36 have scores of 32.38±10.65 and 38.67±11.40, respectively. CONCLUSION: Our results shows that podiatric problems in SSc patients are common, serious but foot assessment and health care are inadequate. Thus, foot health information should be improved in order to better empower patients to self-manage low risk problems and help identify high-risk problems, which require specialist care.

Is an intervention with a custom-made splint and an educational program useful on pain in patients with trapeziometacarpal joint osteoarthritis in a daily clinical setting?

AIM: Custom-made splints may be useful in the conservative treatment of osteoarthritis (OA) of trapeziometacarpal (TMC) joint OA. Our aim was to evaluate usefulness of a custom-made splint and educational program in patients with symptomatic TMC joint OA in daily clinical practice. METHODS: Fifty patients with symptomatic TMC joint OA, not treated with surgery, were enrolled in a open prospective study in a clinical day setting and treated with a 'butterfly' custom-made thermoplastic short opponens splint to be worn 16 h/day for 30 days and then when needed, for 12 months. Patients were evaluated at enrolment (T0), at the first month (T1) and at the 12th month (T2) since splint application for pain (main outcome measure) by numeric rating scale 0-10. At T0 and T1, a Jamar dynamometer (kg) was used to assess hand strength, a pinch gauge to evaluate pinch strength (kg) and Dreiser test to assess hand disability (secondary outcome measures). RESULTS: The comparison between T0 and T1 showed a significant improvement in all the outcome measures (P < 0.0001 for pain, muscle and pinch strength; P = 0.001 for Dreiser test). Moreover, at the end of 12 months follow-up, patients maintained the reduction of pain (T2 vs. T1, P = NS) and showed a reduced consumption of analgesics (P < 0.05). CONCLUSIONS: A custom-made thermoplastic short opponens splint for 30 consecutively days for at least 16 h/day, followed by occasional use on pain outbreak is an useful conservative treatment in symptomatic TMC joint OA.

Ischemia-hyperpnea test is useful to detect patients with fibromyalgia syndrome.

OBJECTIVE: To demonstrate the prevalence of neuromuscular hyperexcitability in Fibromyalgia Syndrome (FMS) by electromyography ischaemia-hyperpnea test (IHT) and its correlation with clinical and clinimetric parameters. MATERIAL AND METHODS: One hundred and forty-five FMS patients underwent IHT to evaluate neuromuscular hyperexcitability and were evaluated for pain (numeric Rating Scale and Regional Pain Scale), tenderness (tender points), disability [Fibromyalgia Impact Questionnaire (FIQ), Health Assessment Questionnaire (HAQ)], quality of life (QOL) [Short Form 36 (SF36)], mood [Hospital Anxiety and Depression Scale (HADS)], sleep [numeric rating scale (NRS)], and fatigue [Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT)]. RESULTS: Of the 145 patients, 95 were tested positive by IHT, and 33 and 17 patients were negative and borderline, respectively. By comparing the three groups, IHT positive patients had lower age and lower SF36 vitality (V), social activities (SA), and mental summary index (MSI) than negative patients (p<0.05). By comparing positive versus negative patients and by comparing positive and borderline patients versus negative patients, it was found that FACIT was higher, whereas age, SF36 V, SA, mental health (MH), and MSI were lower (p<0.05). CONCLUSION: FMS patients present a high prevalence of neuromuscular hyperexcitability, as assessed by IHT. IHT positive patients have poor QOL and higher fatigue than IHT negative patients. Thus, IHT positivity could identify FMS patients with a more severe disease.

A comparison of two podiatric protocols for metatarsalgia in patients with rheumatoid arthritis and osteoarthritis.

OBJECTIVES: In rheumatoid arthritis (RA) and osteoarthritis (OA) forefoot involvement causes disability and metatarsalgia. Our objective was to evaluate, in RA and OA patients, the efficacy of two protocols combining insoles in polypropylene terephtalate (PPT) and custom silicone orthoses for toes on disability and metatarsalgia. METHODS: Twenty-four women (13 with OA, 11 with RA) with metatarsalgia were treated with two protocols: group A (protocol A) wore PPT insoles (T1) for 30 days and for another 30 days silicone orthosis for toes were added (T2). Group B (protocol B) wore PPT insoles and silicone orthosis (T1) for 30 days and in the following 30 days only insoles (T2). At T0, T1 and T2, pain, disability and function (Foot Function Index - FFI), pressure (KPA) and plantar contact areas (cm2) (baropodometer), and gait spatial-temporal parameters (GAITRite®) were assessed. RESULTS: At T0 versus T2, both protocols reduced FFI-pain, -disability and -functional limitation (p<0.05), with better results of protocol A than protocol B (p<0.05) for FFI-pain and -disability. Both protocols reduced baropodometer foot plantar pressures (p<0.001), with better results for protocol A for right foot pressures (p<0.05) and increased foot contact areas (p<0.05), with no difference between them (p=NS). Gait parameters were not significantly changed by both protocols (p=NS). CONCLUSIONS: In patients with RA and OA with metatarsalgia, the synergic action of silicone toe orthosis and PPT insoles improves FFI, reduces foot plantar pressures and increases foot plantar contact areas. Protocol A, using firstly insoles and then adding silicone toe orthoses, is the more efficacious.

Sexual function in Italian women with systemic sclerosis is affected by disease-related and psychological concerns.

OBJECTIVE: In patients with systemic sclerosis (SSc), sexual function is somewhat impaired. Our aim was to evaluate sexual function in women with SSc in comparison to controls, and to investigate the association with sociodemographic and disease characteristics, and physical and psychological variables. METHODS: Forty-six women with SSc and 46 healthy women were assessed for sociodemographic characteristics and gynecological development and administered the Female Sexual Function Index (FSFI), Medical Outcomes Study Short Form-36 (SF-36), Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale, Coping Orientation to Problems Experienced-New Italian Version, and Functional Assessment of Chronic Illness Therapy-Fatigue Scale. Patients were also assessed for disease duration and subset, Female Sexual Function in SSc, Hand Mobility in Scleroderma test (HAMIS), Cochin Hand Functional Disability Scale, Mouth Handicap in Systemic Sclerosis Scale (MHISS), Disability Sexual and Body Esteem Scale (PDSBE); and fist closure, hand opening, and mouth opening. RESULTS: In patients with SSc, only FSFI desire subscale score was significantly lower (p = 0.035) versus controls. Total FSFI score, similar to controls, was related with Medical Outcomes Study Short Form-36 mental component, HAQ (p = 0.022), MHISS (p = 0.038), and HAMIS (p = 0.037). In SSc, the main factors independently associated with sexual functioning were vaginal dryness [regression coefficient (B) = -0.72; p < 0.001], PDSBE (B = 0.42; p = 0.001), and HADS depression scale (B = -0.23; p = 0.035). Together, these variables explained 70% of the variance in the FSFI total score. CONCLUSION: In SSc, sexual function, although not different from controls, is influenced by specific disease-related and psychological concerns. Thus it should be included in patient evaluations and assessed in daily clinical practice.

In systemic sclerosis, anxiety and depression assessed by hospital anxiety depression scale are independently associated with disability and psychological factors.

BACKGROUND: Anxious and depressive symptoms are frequent in Systemic Sclerosis (SSc). Our objective is to assess their prevalence and association with district and global disability and psychological variables. METHODS: 119 SSc patients were assessed by Hospital Anxiety Depression Scale (HADS). Clinical depression and anxiety were defined for HADS score cutoff ≥ 8. Patients were assessed for psychological symptoms (RSES, COPE-NIV), hand (HAMIS, CHFDS, fist closure, and hand opening) and face disability (MHISS, mouth opening), global disability, and fatigue (HAQ, FACIT). RESULTS: Both depression and anxiety in SSc are 36%. Depressive patients with comorbid anxiety have higher HADS-D score than patients with depression only (P = 0.001). HADS-A and -D are positively correlated with global disability, hands and mouth disability, fatigue, self-esteem and avoidance coping strategy, and, only HADS-A, also with social support (P < 0.05). By multiple regression, HADS-D is independently associated with FACIT-F (P < 0.001), RSES (P < 0.001), and MHISS total score (P = 0.016), together explaining 50% of variance. HADS-A is independently associated with RSES (P = 0.006), COPE-NIV SA (P = 0.003), COPE-NIV SS (P = 0.008), FACIT-F (P = 0.022), and MHISS mouth opening (P = 0.029), explaining 41% of variance. CONCLUSIONS: In SSc depression and anxiety correlate to local and global disabilities and psychological characteristics. Depressive patients with comorbid anxiety have higher level of depressive symptoms.

Gynaecological symptoms and sexual disability in women with primary Sjögren's syndrome and sicca syndrome.

OBJECTIVES: This paper aims to investigate women with primary Sjögren's syndrome (pSS) and sicca syndrome (SS), focusing on the prevalence of disease-related symptoms and their impact on sexual ability, relationship, communication about sexuality with partner and health professionals (HP). METHODS: Sixty-two women with pSS and 33 with SS were assessed for sexual activity, relationship with partner, communication about sex; for physical disability and body esteem, fatigue, disability, quality of life (QoL), anxiety and depression. RESULTS: Around 55% patients had a relationship; >79% and around 70% at least 1 gynaecological (especially dryness), and 1 muscle-skeletal symptom, respectively; around 60% sex disability for disease-related symptoms, mainly dryness (p=NS for all comparisons between pSS and SS). In both groups, disease changed sexual activity (around 50%), causing limitation (around 50%) and reduced frequency (>80%) in sexual intercourses; sex pleasure and satisfaction were around 30% and 25% (p=NS for pSS vs. SS). Around 55% patients discussed with partner disease-effects on relationship; despite in around 70% partner understood difficulties, in around 34% disease altered relationship (p=NS for pSS vs. SS). Around 16% patients were asked by HP if disease affected sexuality, around 30% never approached anyone to discuss about sex (p=NS for pSS vs. SS). Disability, QOL, mood, fatigue, similar in pSS versus SS (p=NS), were not affected by xerostomia and xeroftalmia, but by sex concerns and sex disability. CONCLUSIONS: Patients with pSS and SS present, often and at the same extent, gynaecological symptoms, leading to impaired sexual intercourse, affecting pleasure, satisfaction, sexual ability.

A manual therapy intervention improves symptoms in patients with carpal tunnel syndrome: a pilot study.

In carpal tunnel syndrome (CTS), manual therapy interventions (MTI) reduce tissue adhesion and increase wrist mobility. We evaluated the efficacy of a MTI in relieving CTS signs and symptoms. Twenty-two CTS patients (pts) (41 hands) were treated with a MTI, consisting in 6 treatments (2/week for 3 weeks) of soft tissues of wrist and hands and of carpal bones. Pts were assessed for hand sensitivity, paresthesia, hand strength, hand and forearm pain, night awakening; Phalen test, thenar eminence hypotrophy and Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) and Functional Status Scale (FSS). Median nerve was studied by sensory nerve conduction velocity (SNCV) and distal motor latency (DML). CTS was scored as minimal, mild, medium, severe and extreme. We considered as control group the same pts assessed before treatment: at baseline (T0a) and after 12 weeks (T0b). Pts were evaluated at the end of treatment (T1) and after 24-week (T2) follow-up. At T0b, versus T0a, forearm pain and Phalen test positivity were increased and hand strength reduced (p < 0.05). BCTQ-SSS and BCTQ-FSS scores improved at T1 versus T0b (p < 0.05) with the amelioration maintained at T2. At T1, the number of pts with paresthesia, night awakening, hypoesthesia, Phalen test, hand strength reduction and hand sensitivity was reduced with the lacking of symptoms maintained at T2 (p < 0.05). No changes in SNCV, DML and CTS scoring were shown. MTI improved CTS signs and symptoms, with benefits maintained at follow-up. Thus, it may be valid as a conservative therapy.

Rességuier method and Qi Gong sequentially integrated in patients with fibromyalgia syndrome.

OBJECTIVES: In fibromyalgia syndrome (FMS), the Rességuier Method (RM) and Qi Gong (QG) can be efficacious. QG aims to improve posture, respiration, concentration, while RM aims to obtain patient awareness and control of pain perception. We evaluate 2 protocols integrating RM and QG in FMS. METHODS: Thirty FMS patients were assigned to Group 1, treated by RM and then by QG or Group 2, treated by QG and then by RM. In both protocols, patients are treated 7 weeks by each technique (with 1 week interval), and followed up for 12 weeks. Patients were assessed at T0, at end of 1st (T1) and 2nd intervention (T2), at follow-up (FU) by number rating scale (NRS) for sleep quality and pain, Regional Pain Scale (RPS),Tender Points (TPs), FIQ, HAQ, SF36, HADS for anxiety and depression (HADS-a/d). RESULTS: In Group 1 at T1 (after RM), NRS for pain, RPS, FIQ, HAQ were reduced, HADS-a and SF36 ameliorated; at T2 (after QG) FIQ were further reduced and TPs and HADS-d improved; HADS-a and SF36 maintained. In Group 2 at T1 (after QG), NRS for pain, RPS, TPs, FIQ, HAQ, reduced with reduction maintained at T2 (after RM). HADS-a and -d and SF36 ameliorated at T1, with improvement confirmed at T2; sleep quality ameliorated only at T2. Effects of both protocols are similar at T2 and maintained at FU. CONCLUSIONS: In FMS, both protocols improve pain, disability, quality of life, tenderness, anxiety. RM also ameliorates sleep and QG improves depression. Sequential integration of RM and QG is efficacious in FMS.

CCL2, CCL3 and CCL5 chemokines in systemic sclerosis: the correlation with SSc clinical features and the effect of prostaglandin E1 treatment.

OBJECTIVES: Chemokines favour leukocyte homing and participate actively in inflammation and accumulation of extracellular matrix. The aim of our work is to assess in patients with systemic sclerosis (SSc) the serum levels of CC chemokines: CCL2 monocyte chemotactic protein-1 (MCP-1/CCL2), CCL5 'regulated upon activation, normal T expressed and secreted' (RANTES/CCL5) and CCL3 'macrophage inflammatory protein 1 α' (MIP1α/CCL3), their associations with clinical characteristics and modulation by infusions of the prostaglandin E1 (PGE1) analogue, alprostadil alpha-cyclodextrin. METHODS: Serum levels of MCP1/CCL2, RANTES/CCL5 and MIP1α/CCL3 were studied by ELISA in 40 patients with SSc (34 lSSc, 6 dSSc) before and after 3 consecutive daily PGE1 infusions (60 µg) and compared to 30 healthy controls. We recorded clinical (age, duration of disease, ulcers, teleangectasias, calcinosis, skin score [mRSS], capillaroscopy pattern, heart and lung involvement) and immunological characteristics (ANA/ACA/Scl70) of patients. RESULTS: MCP1/CCL2, RANTES/CCL5 and MIP1α/CCL3 levels were significantly higher in SSc patients than in controls and significantly decreased after PGE1 treatment. MCP-1 levels, higher in dSSc and Scl 70 positive patients, correlated with mRSS. CONCLUSIONS: The high levels of circulating chemokines might support a role of MCP1/CCL2, RANTES/CCL5 and MIP1α/CCL3 in SSc pathogenesis and the correlation of MCP-1 with the extent of skin fibrosis might imply its involvement in the development of fibrosis in SSc. PGE1 down-regulates serum MCP1/CCL2 and RANTES/CCL5 levels, suggesting its possible additional effect on inflammation and cell trafficking in SSc.

CXCL11 in bronchoalveolar lavage fluid and pulmonary function decline in systemic sclerosis.

OBJECTIVES: Several studies have focused on the antifibrotic potential of the Th1 cytokine IFN-γ-1b through suppression of Th2 fibrogenic functions. It has been reported that IFN-γ induces the production of CXCL11 in the lung and plasma of patients with lung-fibrosis. The aim of the present study was to determine whether the levels of CXCL11 in the bronchoalveolar lavage fluid (BALF) of SSc patients might be a predictor of clinically significant fibrotic lung involvement. METHODS: In a retrospective longitudinal study we analysed BALF samples from 16 SSc patients with interstitial lung disease (ILD) and 16 matched control patient without ILD. Patients were eligible if they did not have evidence of ILD at the time of BAL as shown by HRCT. A standard morphological and immunological analysis of BALF cellular components was performed. CXCL11 was measured in BALF by specific ELISA assay. RESULTS: BALF CXCL11 concentrations were significantly elevated in the samples taken from patients who did not developed ILD as compared to those who developed ILD (p<0.001). Stepwise logistic regression analysis revealed that BALF CXCL11 levels predicted clinically significant ILD (p<0.001). CONCLUSIONS: The presence of elevated BALF concentrations of CXCL11 in SSc patients who do not developed lung fibrosis suggest that determination of CXCL11 in BALF could serve as a prognostic factor for pulmonary function decline.

Manual lymph drainage improving upper extremity edema and hand function in patients with systemic sclerosis in edematous phase.

OBJECTIVE: In systemic sclerosis (SSc; scleroderma) patients in edematous phase, hand edema is often present. Manual lymph drainage (MLD) stimulates the lymphatic system and reduces edema. Our aim was to evaluate the efficacy of MLD in reducing edema and in improving functionality of the hands and perceived quality of life (QOL) in SSc patients in edematous phase. METHODS: Of 35 SSc patients with edematous hands, 20 were treated with MLD according to the Vodder technique once a week for 5 weeks (intervention group), and 15 served as the observation group. Patients were evaluated at enrollment, at the end of treatment (T1), and after 9 weeks of followup (T2) by volumetric test (assessing hand volume), the Hand Mobility in Scleroderma (HAMIS) test, and 4 visual analog scales (VAS; scored 0-10) evaluating the perception of hand edema and pain and their interference on daily activities. QOL and disability were assessed by the physical synthetic index (PSI) and mental synthetic index (MSI) of the Short Form 36 (SF-36) and by the Health Assessment Questionnaire (HAQ). RESULTS: In the intervention group, hand volume, the HAMIS test, and the 4 VAS were improved significantly at the end of treatment (P < 0.001). The results were maintained at T2 (P < 0.001). The HAQ and the PSI and MSI of the SF-36 also improved significantly at T1 (P < 0.001), but only PSI improvement was maintained at T2 (P < 0.001). In the observation group, no improvement at T1 and at T2 was observed. CONCLUSION: In SSc, MLD significantly reduces hand edema and improves hand function and perceived QOL.

Efficacy of connective tissue massage and Mc Mennell joint manipulation in the rehabilitative treatment of the hands in systemic sclerosis.

Rehabilitation may contribute to the management of systemic sclerosis (SSc) dealing with disabilities due to hand involvement. The aim of this study is to evaluate the efficacy of a rehabilitation programme based on the combination of connective tissue massage and Mc Mennell joint manipulation specifically conceived for SSc patients' hands. Forty SSc patients were enrolled: 20 (interventional group) were treated for a 9-week period (twice a week, 1 h per session) with a combination of connective tissue massage, Mc Mennell joint manipulation and home exercise programme, and 20 (control group) were assigned only to home exercise programme. Patients of both groups were assessed at baseline (T0), after 9 week (T1) and at a 9 weeks follow-up (T2). They were evaluated for quality of life by SF-36 and Health Assessment Questionnaire (HAQ), hands involvement by Hand Mobility in Scleroderma (HAMIS) test, Cochin hand functional disability scale and the measurements of ROM. In the interventional group, fist closure, HAMIS test and Cochin hand functional disability scale improved at the end of the treatment (p < 0.0001) as well as HAQ, Physical Synthetic Index (PSI) and Mental Synthetic Index (MSI) of SF-36 scores (HAQ and PSI, p < 0.0001; MSI, p < 0.001). In the control group, the programme of home daily exercises improved only fist closure at the end of the treatment (p < 0.0001). The combination of connective tissue massage, Mc Mennell joint manipulation and home exercise programme is effective in the rehabilitative treatment of SSc hands. This combined treatment may lead to an improvement of hand function and quality of life.